Treatment of the single tooth extraction site

Oral Maxillofacial Surg Clin N Am 16 (2004) 41–63

Treatment of the single tooth extraction site

Michael S. Block, DMD

Department of Oral and Maxillofacial Surgery, Louisiana State University School of Dentistry, 1100 Florida Avenue,

New Orleans, LA 70119, USA

The removal of a tooth initiates a sequence of from load transferred to the bone surface, not only

events including inflammation, epithelialization, and

remodeling. Sockets heal by secondary intention, with

remodeling continuing to 1 year after the extraction

before the site is indistinguishable from adjacent

edentulous bone. When a tooth is removed, the empty

socket consists of cortical bone known as the lamina

dura, torn periodontal ligaments, and a rim of oral

epithelium. The socket fills with blood, which clots

and seals the socket from the oral environment. The

inflammatory stage of healing occurs during the first

week. White blood cells enter the site and remove

debris and break down remaining bone fragments

and other soft tissue remnants. Fibroblasts and capil-

laries infiltrate the socket. The epithelium migrates

down the wall of the socket until it reaches epithelium

from the other side or encounters a bed of granulation

tissue over which it can migrate. The second week has

a large amount of granulation tissue filling the socket.

Osteoid deposition begins along the alveolar bone

lining the site. These processes continue during the

third and fourth weeks, with epithelialization com-

plete by the fourth week and earlier in small sites [1].

Woven bone is formed and fills the extraction site by

8 weeks [2]. Cortical bone continues to be resorbed

from the walls of the socket, with new trabecular bone

laid down across the socket. As shown by Atwood [3],

however, the process of bone remodeling may vary

significantly between individuals. The layer of com-

pact bone may fail to regenerate [4], resulting in

exposure of the cancellous bone in the alveolar ridge.

Further resorption can then occur. Bone loss follow-

ing tooth extraction may amount to 0.5 mm per year.

Bone resorption is affected by overlying pressures

1042-3699/04/$ – see front matter D 2004 Elsevier Inc. All right

doi:10.1016/j.coms.2003.10.007

E-mail address: [email protected]

from within the bone [5].

Based on the previous discussion, the decision of

what to do when extracting a tooth that is treatment

planned for implant placement includes a sequence of

events that will preserve and often create the neces-

sary bone for implant stabilization. Several therapies

can be offered to the patient; the decision tree shown

in Fig. 1 depicts such interceptive strategies. The

tooth can be extracted and the resultant bone deficit

grafted after the extraction site has healed. Another

treatment is to degranulate the extraction site and

place a graft to preserve and reconstruct the defect.

When the tooth root size indicates that it can be

replaced with an implant with adequate mechanical

stability to allow for immediate provisionalization, the

patient can have the tooth provisionally replaced at

the same time as extraction.

Extraction of teeth without grafting: implications

for implant placement

Following extraction of teeth, bone loss may be

significant, resulting in less than ideal bone available

for implant placement. The bone loss may include the

labial/facial bone, resulting in horizontal or vertical

deficiency with loss of interseptal, mesial, or distal

bone, depending on the etiology leading to tooth ex-

traction, such as severe periodontal disease or chronic

bone loss from tooth fracture. Even after a ‘‘clean’’

extraction, bone loss may unpredictable, resulting

in limitation of ideal implant placement. Labial or

facial resorption may be rapid or delayed, resulting in

loss of adequate bone width and height for ideal im-

plant placement.

s reserved.

Fig. 1. Decision tree for interceptive strategies when considering implant placement in an extraction site.

M.S. Block / Oral Maxillofacial Surg Clin N Am 16 (2004) 41–6342

To document the incidence of this problem in the

anterior maxilla, a prospective series of patients was

evaluated at the author’s institution. All of the patients

had single tooth replacement in the anterior maxilla

when the recipient site had the tooth extracted without

grafting the socket. In the prospective trial, all

implants followed a two-staged protocol that allowed

for undisturbed implant healing and integration before

exposure and loading. All sites were edentulous for

at least 8 weeks before placing the implants and were

in the anterior maxilla. None of the extraction sites

had been grafted before placement of implants [6].

Consecutive patients without exception were ac-

cepted if they did not smoke, had no systemic disease

that would inhibit wound healing, and had no active

periodontal disease in their remaining teeth. All

patients required single tooth implant restorations in

their maxilla from first premolar anterior. Each patient

had standardized radiographs taken using a custom-

fabricated film holder and had a diagnostic setup for

surgical guide stent fabrication. The surgeon decided

on the need for hard tissue grafting and a prostho-

dontist determined the need for soft tissue grafting.

The implants used were hydroxylapatite-coated

threaded titanium (n = 25) or relatively smooth-

machined titanium (n = 24), both from Nobel Biocare

(Yorba Linda, California).

Forty-nine patients were prospectively evaluated.

Five first premolars, 5 canines, 15 lateral incisors,

and 24 central incisors were restored. Twenty-eight of

49 (57%) required hard tissue grafting due to deficient

ridge width. The predominant treatment of apical

fenestrations (n = 7) and middle implant fenestrations

(n = 8) was grafts without membrane coverage.

Coronal fenestrations (n = 10) were treated with grafts

and membrane coverage (Figs. 2–4). Before implant

exposure, 19 of 49 (39%) required (based on the soft

tissue analysis of the prosthodontist) subepithelial

connective tissue grafts, and 5 of 49 (10%) required

a palatal roll-in at the time of implant exposure.

Postexposure procedures included subepithelial con-

nective tissue grafts to reduce vertical scar formation

(n = 4), semilunar flaps (n = 2) to correct gingival

discrepancies, gingivoplasty (n = 3), and crown-

lengthening procedures (n = 2). This prospective

evaluation indicated that most delayed (two-staged)

M.S. Block / Oral Maxillofacial Surg Clin N Am 16 (2004) 41–63 43

anterior maxillary single tooth implant restorations

require hard or soft tissue grafts to optimize the

anterior maxillary single tooth implant restoration.

Crestal bone level changes

The integration incidence was 48 out of 49. Under

magnification, a caliper was set to measure one

thread distance. The caliper was then used on stan-

dardized periapical radiographs to measure the level

of the bone in relation to threads of the implants. With

the interperiodicity distance of the threads known from

the manufacturer, a precise measure of the bone dis-

tance to the shoulder of the implant was determined.

Using the worst value of the mesial or distal crestal

bone level, the level of the bone at time of implant

placement was �2.04 F 1.54 mm (a negative value

denotes coronal position in relation to the shoulder of

the implant, a positive value denotes bone apical to the

shoulder of the implant). At the time of implant

exposure, the bone level was �1.20 F 1.49 mm and

at the time of placement of the final restoration, it was

�0.34 F 1.19 mm. The corresponding serial crestal

bone levels were �0.17 F 1.08 mm (6 months),

�0.13 F 1.06 mm (12 months), �0.30 F 0.81 mm

(18 months), and �0.38F 0.84 mm (24 months). The

polished collar for these implants is 0.75 mm. Thus, at

2 years after restoration, the crestal bone levels

changed less than 1.5 mm after 1 year and 0.2 mm

every year thereafter [6]. Crestal bone levels were

stable over time for single tooth implant restorations.

Soft tissue position changes

After placement of the final restoration in these

patients, the distance from the incisal edge to the facial

gingival margin was measured. In addition, from the

photographs taken at each follow-up visit, the pres-

ence of the papilla was assessed by two prosthodon-

tists not involved in the treatment of these patients.

The results of these soft tissue position assessments

indicated that the papilla filled the embrasures with an

index (0–3) of 2.43 (mesial) and 2.33 (distal) after

2 years of follow-up. The gingival margin moved an

average of 0.4 mm from the 6-month follow-up visit

to the 24-month follow-up visit, indicating stability of

the gingival margin.

Conclusions that can be drawn from placing

implants into extraction sites that did not have socket

grafting include (1) the bone loss following extraction

of an anterior tooth without grafting results in thin

ridges that require adjunctive hard tissue grafting in

over 50% of sites; and (2) after the implants are

placed, the crestal bone and soft tissue levels are

stable over time.

This prospective evaluation clearly demonstrates

the need for intercepting the extraction site’s normal

course of healing by graft the site at the time of

tooth extraction.

Grafting the extraction site at time of tooth

extraction

The reasons for extracting a tooth include the

presence of infection and often the destruction of a

tooth that prevents its restoration. Therefore, for a

grafting material to be successful, it must be able to

be placed in the face of infection. The author pre-

medicates patients with antibiotics and a chlorhex-

idine rinse 5 days before surgery to decrease the

bacterial flora at the time of extraction and grafting.

Types of graft materials

Graft materials include autogenous bone, allo-

grafts, xenografts, and synthetic materials. To be

successful, the graft material must be able to do

the following:

1. Maintain the space of the extraction site and

prevent its collapse.

2. Allow for rapid revascularization and cell

migration to promote bone healing.

3. Allow for bone formation to occur with slow

resorption of the material placed into the site to

maintain the space and, thus, result in sufficient

bone dimensions for implant stability.

4. Allow for epithelial coverage of the extraction

socket without the need for primary closure of

the extraction site, thus preserving the normal

gingival architecture and appearance by avoid-

ing excessive gingival manipulation.

5. Heal uneventfully in the face of active chronic

infection.

Multiple types of bone materials have been advo-

cated to preserve and optimize the amount of bone

that fills in the extraction site before implant place-

ment. Autogenous bone can be harvested from neigh-

boring sites in the jaws and represents an excellent

standard; however, donor site morbidity does not

make this choice ideal in all patients.

Allografts are treated in bone banks in a variety

of methods, resulting in different mineralized, freeze-

dried, solvent-dehydrated, or demineralized states

Fig. 2. (A) Preoperative view. The tooth to be extracted is the right central incisor. (B) The tooth after extraction secondary to

external resorption below the alveolar crest. No graft was placed after the extraction was performed. (C) After 8 weeks, there was

a labial deficiency. The implant was placed and a midfacial dehiscence of the implant surface was seen after its placement.

(D) The facial dehiscence was grafted with dense, nonresorbable hydroxylapatite. (E) After 14 weeks, there was still a deficiency

in the horizontal width of the ridge. A crestal incision was made and a subepithelial pouch created to receive a connective tissue

graft. (F) A subepithelial connective tissue graft was harvested from the palate. A superficial dissection was made and the

subepithelial connective tissue was harvested, including the periostium. (G) The connective tissue was cleaned and trimmed to

appropriate shape. (H) After the graft had healed for 6 weeks, a tissue punch was used to expose the implant and a healing

abutment was placed. (I) A temporary restoration was made to allow for proper development of the sulcular morphology. Shown

is the temporary abutment before final impressions. (J) The final abutment chosen was ceramic to create ideal esthetic. (K) The

final restoration. (Prosthetics by Dr. Thomas Salinas.)


with or without carriers of different molecules. Allo-

grafts are advantageous because they can be stored on

the shelf and provide ease of use without donor site

morbidity. Although there has not been any reported

contamination with life-threatening viruses or bacte-

ria after sterilization and preparation of allogeneic

bone, some patients prefer to avoid the use of ma-

terials from another human.

Xenografts are mostly derived from bovine sour-

ces and are deproteinized by chemical or heat methods

Fig. 2 (continued).


to provide a clean material based predominantly on

the mineralized matrix. The xenografts are provided

from cortical, cancellous, or a mixture of both bone

sources. Some clinicians believe that cortical bone

particles resorb slower than cancellous bone particles,

but this has not been conclusively shown in situ.

Synthetic materials are based on glass or calcium

phosphates, with or without the addition of other

materials such as calcium sulfate. The advantages

of these materials are ease of use, excellent shelf

life, lack of immune rejection, and lack of disease

transmission. The disadvantages are different re-

sorption rates, lack of intrinsic growth factors that

are presumed to aid in bone formation when using

natural bone products, and different porosities that

may prevent, inhibit, or accelerate cellular and vascu-

lar ingrowth.

All of the previously mentioned materials have

limited prospective trial literature; hence, much of

what is recommended is based on less than ideal trials

or relies on personal experience. To preserve alveolar

bone width and height for implant placement or for

prosthetic concerns, allografts, xenografts, and allo-

plasts have been used to graft the extraction site.

Allografts

Mineralized bone allografts have been used for

variety of applications. Because bone contains organic

and inorganic material, the cellular reaction to the

processed mineralized bone will be dependent on the

specific method of processing. Becker et al [7] dem-

onstrated that mineralized bone obtained from a bone


Fig. 3. (A) A 58-year-old man who lost his left central incisor 5 years before current presentation secondary to fracture of a

post that was secondary to trauma. The tooth was extracted and no graft placed at time of extraction. Note the labial horizontal

deficiency. (B) Periapical radiograph. Note that the crestal bone levels on the adjacent teeth are at the levels of the

cementoenamel junction, which indicates that papilla support should be present for the final restoration. (C) Sulcular incisions

avoiding vertical release were used to access the crest. After the full-thickness flap was raised, the implant was placed. Note the

lack of horizontal bone and ridge projection. (D) A graft of dense, nonresorbable hydroxylapatite was placed to augment

the horizontal projection of the crest. (E) The final restoration in place. There was no need for soft tissue grafting because of the

successful use of the alloplastic augmentation at time of implant placement. (Prosthetics by Dr. Avishai Sadan.) (F) Final

periapical radiograph 3 years after delivery of restoration. Note preservation of the crestal bone on the adjacent teeth.

E

Fig. 4. (A) This 24-year-old woman had agenesis of her lateral incisors. Deciduous laterals were extracted and she was not restored

for 3 years. For implant placement, sulcular incisions were used to access the crestal bone. (B) The implant (3.25-mm diameter)

was placed. No hard tissue was graft was placed, even though there was an obvious horizontal projection deficiency present.

(C) After 14 weeks, the ridge was noted to be horizontally deficient. The patient now requires a soft tissue augmentation to achieve

a satisfactory esthetic restoration. (D) A crestal incision was made and a pouch/pocket formed to allow the placement of

a subepithelial connective tissue graft. The graft was placed and the patient allowed 6 weeks before implant exposure. (E) A small

circular incision was used to access the implant’s cover screw. A straight emergence profile healing abutment was placed. Note the

restoration of the horizontal projection of the gingiva. (F) The final restorations after 3 years of function. (Prosthetics by

Dr. Thomas Salinas.)



bank without removal of the organic matrix may not

have an adverse antigenic response when implanted.

Allografts such as demineralized freeze-dried bone

and solvent-dehydrated mineralized bone have been

advocated for use in extraction sites because of their

osteoconductive nature and the characteristic that

they will resorb and be replaced within a relatively

short period of time, depending on their density and

preparation technique. A reported series of patients

demonstrates the use of a solvent-dehydrated miner-

alized bone to preserve bone height and bulk with

eventual implant placement [8].

Soft tissue such as dura mater or fascia lata has

been processed with the solvent-dehydration tech-

nique (Tutoplast process, Tutogen Medical, Neun-

kirchen, Germany) and are well tolerated [9–11].

Before applying the solvent-dehydration method to

bone, cancellous bone is harvested from donors who

have been screened for transmissible diseases. The

bone is delipidized with acetone and the cells are re-

moved to lower the antigenicity. An oxidative treat-

ment destroys the remaining proteins and minimizes

graft rejection by removing proteins and inactivating

enzymes. The bone is then dehydrated by solvents,

which removes the water from the tissue. The process

is concluded by limited-dose gamma irradiation [11].

The cellular reaction to bone processed using the

solvent-dehydration method has been assayed in ani-

mal models. Primary periosteal osteoblast adhesion

and measured cell activities were better with the

solvent-dehydrated bone compared with controls

[12]. In an animal model designed to evaluate bone

healing, 84 cylindric bone defects were created in the

femoral condyles of rabbits. Grafts included cryopre-

served cancellous bone, solvent-dehydrated gamma

irradiated human bone, or bovine bone. There were

no differences between cryopreserved and solvent-

dehydrated irradiated bone. The solvent-dehydrated

group showed isolated foci of osteoclasts starting

the remodeling process at 4 weeks. At 8 to 12 weeks,

the marrow in the defects had the appearance of sec-

ondary mature marrow, with fat and hematopoietic

cells. At 26 weeks, the human mineralized solvent-

dehydrated bone graft was not apparent in any animal

except one [13]. Solvent-dehydrated mineralized bone

allografts have been used to repair long bone defects

resulting from trauma and for prosthetic revision. The

preliminary conclusions were that human dehydrated

and chemically extracted bone yielded very positive

results [14]. In the maxillofacial region, small clinical

series have been reported using human mineralized

bone for treatment of cyst defects and for ridge

augmentation. Twenty-eight patients were treated for

repair of cystic defects. Successful clinical results

were reported, with bone filling the defects [15].

Eighteen patients had nine sandwich and nine onlay

grafts performed using human mineralized bone

alone. Fifteen cases were successful and 3 failed, with

loss of graft [16].

Human mineralized bone or other allograft can

be placed using a technique similar to that presented

by Sclar [17]. The techniques are described in a

following section. Human mineralized bone has been

placed in multirooted molar sites and in single rooted

sites in the mandible and maxilla. After 4 months of

bone healing, implants were successfully placed and

often immediately provisionalized. The bone density

was sufficient to require greater than 25 NCm of

insertion torque to place the implants in 75% of the

cases. When there was doubt of the hardness of the

graft, a two-staged protocol for delayed implant res-

toration was used, with 4 months allowed for implant

integration before loading. When evaluated subjec-

tively, the graft sites (human mineralized bone) healed

with retention of original ridge form without the

presence of infection, even when placed into an

infected site [8]. After 3 weeks, complete epitheliali-

zation was found across the single rooted sites, which

had been covered with a collagen material.

Follow-up evaluation for up to 2 years indicated a

stable bone response at the coronal aspect, with bone

levels settling to the level of the first thread of the

implant, without evidence of excessive crestal bone

loss of the graft over time.

With limited follow-up, short-term results indicate

potential for restoration of the extraction site’s bone

height and width using mineralized bone, preserving

or recreating the site’s bone bulk for implant place-

ment without adjunctive grafting procedures.

Xenografts

Xenografts are graft materials harvested from a

species other than human, typically bovine, and are

processed to remove the antigenicity by a variety of

chemical and preparation techniques. Xenografts have

been successfully used for the preservation of extrac-

tion site bone [17]. In the author’s experience [18], the

graft particles are clearly present at 4 months, with

minimal signs of resorption or replacement. The graft

is firm but requires less than 25 NCm to place

implants, which is less than the previously mentioned

human mineralized bone.

To decrease the adverse cell reaction to implanted

mineralized bone and to use a source easier to obtain

than human material, anorganic or deproteinized bo-

vine bone material has been developed for use as a


bone graft substitute. Deproteinized bovine bone is

an anorganic, pathogen-free bovine bone that is a

carbonate-containing apatite. It has a crystalline

architecture and a calcium/phosphate ratio similar to

natural bone mineral in humans. Bovine-derived cor-

tical mineralized material has been shown to have

excellent osteoblast adhesion [19,20] and promote

bone formation in critical-size calvarial defects [21],

and can support bone formation around teeth, endo-

sseous implants, and in ridge augmentation [22–24].

The absence of proteins results in minimal immune

response in vivo [25,26]. In bone defects or extraction

sites, deproteinized bovine bone resulted in bone fill

with a similar appearance to the control sites, with

bone filling the extraction site [17,18,27–32]. Depro-

teinized bovine bone has been used to graft small

defects between the implant and the labial bone in

conjunction with immediate placement of implants

in extraction sites [33]. Animal studies indicate that

when there is a space or void between the implant and

the walls of the extraction site, the space can be

successfully grafted and result in excellent bone

contact to the implant [34–40]. The resorption rate

of bovine cortical bone is slow, with bovine cortical

bone present after 18 months in situ [25,29,33]. Sclar

[17] showed excellent results using bovine bone with

a collagen membrane covering the extraction site,

leading to bone formation and adequate support of

implants within 4 to 8 months after graft placement.

Synthetic graft materials

Synthetic graft materials include forms of cal-

cium phosphate materials—either dense or porous hy-

droxylapatite [41], hard tissue replacement [42,43],

and bioactive glass [44,45]. These materials have

proved useful for retaining alveolar bulk but can be

slow to resorb because of their chemical character-

istics. Recent advances in adding materials or chang-

ing the chemical characteristics of these materials,

however, recently have been shown to provide main-

tenance of form and also allow for bone formation.

Ridge preservation requires maintenance of

ridge bulk and form. There have been several mate-

rials used in the past that are placed into the extrac-

tion socket but do not resorb. These materials are

classically used for removable preprosthetics or to

achieve esthetic ridge contours for the pontic region of

a fixed prosthesis. To convert a clinically nonre-

sorbable material into a material that can resorb with

bone formation, combinations of materials or changes

in the materials themselves have been developed. An

example of one such material is the use of ‘‘bioactive

glass’’ (Biogran, Implant Innovations, West Palm

Beach, Florida) with calcium sulfate (Calcigen Oral,

Implant Innovations), forming a composite that alleg-

edly resorbs in 8 weeks, with dense bone formation

within the extraction site. This material is supplied as

a powder and liquid that is mixed to form a paste,

combined with the bioactive glass particles, and

placed within the extraction socket. After 3 or more

minutes, the putty hardens and maintains its shape

and position in the site. No sutures are needed and no

membrane is required to keep the material in place.

Epithelialization occurs over the socket. Histologic

evaluation confirms bone formation that can be suffi-

cient for placement and stability of dental implants

[46–48].

Autogenous bone

Autogenous bone is generally considered the

standard with which other bone graft materials are

compared. Autogenous bone is readily available for

use as a graft to extraction sites or for ridge augmen-

tation. Bone can be scraped from adjacent sites,

collected in a sieve after shaving the bone with a

bur, collected with a rongeur forceps from adjacent

sites or the alveolar ridge, or collected as a block from

the symphysis or ramus/body region.

To examine the bone formed in extraction sites

grafted with autogenous bone, biopsies were taken

from extraction sites or dental implant sites that had

been grafted with autogenous bone or other bone

materials. Autogenous bone demonstrated osteocon-

duction, with nonvital particles surrounded by new

bone formation. Autologous bone was eventually

resorbed and replaced by the host. Other bone allo-

grafts, however, were slow to resorb [7].

Autogenous grafts have been compared with other

materials when used for regenerating bone in defects

that resulted after tooth extraction or for thin ridges.

In the dog, lateral ridge augmentation was performed

using autogenous bone block grafts. Results indi-

cated that barrier membranes increase the eventual

bone volume, with autogenous bone having more

bone formation compared with allograft [49]. One

study, however, indicated that when autogenous grafts

were placed in combination with a barrier membrane

and implants were placed after the graft had consoli-

dated, implant survival in the autogenous grafts was

97.5%. Autogenous grafts were similar to other mate-

rials when placed under a barrier membrane in prep-

aration for implant placement [50]. Autogenous

cortical grafts harvested from the chin or ramus have

been successfully used to augment the narrow ridge


in preparation for placement of dental implants, with a

high predictable success rate [51,52]. The mandibular

ramus/body cortical graft was successfully used to

augment a narrow ridge [53].

Autogenous grafts can be obtained as cancellous

particles, cancellous blocks, cortical blocks, or corti-

cocancellous blocks of bone. In the rabbit model,

cancellous autogenous onlay grafts were evaluated.

Cancellous grafts developed a higher bone volume

fraction, mean trabecular thickness, connectivity,

and degree of anisotropy, demonstrating that cancel-

lous grafts healed with a more organized and inter-

connected internal ultrastructure over time [54].

Cortical grafts maintained their volumes significantly

better than cancellous bone grafts. There was no

significant difference in the resorption rates of corti-

cal bone grafts of different embryologic origin. Cor-

tical autogenous grafts have been found to be better

than autogenous particulate cancellous grafts when

used as an onlay graft, in contrast to pure cancellous

grafts [55]. The use of reinforced barrier membranes,

however, may be essential to cover particulate grafts

and have been reported to achieve excellent results.

In defects grafted with a variety of materials with

barrier membranes, autogenous bone grafts had the

best osteoconductive properties during the initial

healing period compared with allogeneic graft mate-

rial [56]. Titanium-reinforced polytetrafluoroethylene

membranes were used to cover autogenous particulate

grafts. Autogenous bone grafts were successful in

regenerating the alveolus and supporting implants

[57]. Ridges previously augmented with autografts

and nonresorbable barrier membranes achieved a

98.3% 5-year success in implants placed into these

ridges, indicating excellent response of the bone to

implant placement [58]. Autogenous bone particles

covered with a barrier membrane were used to aug-

ment thin bone and exposed threads on implants

immediately after placement. The autogenous bone

was able to provide satisfactory regeneration of the

alveolus [59].

Based on the previously referenced discussion, the

use of autogenous bone for regenerating lost bone has

several advantages. In animal and clinical reports,

autogenous bone results in more bone formation

within a site and as an onlay compared with allogeneic

material. When used in extraction sites, the only

disadvantage is concomitant morbidity when an ad-

ditional harvest site is used. If the clinician is extract-

ing multiple teeth, then the bone collected from an

alveloplasty can be particulated and placed into the

sites without the use of allografts or xenografts. If the

patient has a preference to use his or her own bone,

then bone can be collected from the jaws and placed

into the extraction site. The decision to use a barrier

membrane in conjunction with an autogenous graft

will depend on the extent of vertical or horizontal

ridge augmentation necessary. As more of the recon-

struction is beyond the walls of the defect, then the use

of a barrier membrane will augment the final result.

Technique for autogenous bone grafting to the

extraction site

The decision to use autogenous bone for graft-

ing the extraction site is usually made before extract-

ing the tooth. Incision designs should take into

consideration the need for subperiosteal tunneling or

separate incisions to allow for harvesting bone. When

extracting multiple teeth (eg, in preparation for plac-

ing implants into the anterior mandible), alveoloplasty

can be performed and the particulated bone placed

within the extraction sites. An alternative to using

alveoloplasty bone is to use a subperiosteal tunnel

and one of the available bone scraping devices to

collect bone from the external oblique ridge. Another

alternative is to collect bone into a sieve placed in the

suction line. Bone particles can be collected from

implant preparation drills or the use of a round bur

in the chin or body/ramus regions (Fig. 5).

Methods for grafting extraction sites

Patients are good candidates for grafting the ex-

traction site if they have a tooth in need of extrac-

tion, their remaining dentition is in good repair with

no active periodontal disease, and if they are not im-

munocompromised. When grafting the extraction site

without simultaneous implant placement, it is recom-

mended to wait until bone has filled the site, which

may take 4 or more months, depending on the size of

the bone defect and the material used to graft the

socket. For molar sites or single rooted sites with thin

or missing cortical bone (with minimal bone available

for stabilization of the implant), it is recommended to

place a graft into the socket and delay implant

placement for 16 weeks. For single rooted tooth sites

with intact labial and apical bone for initial stabiliza-

tion of the implant and relatively healthy gingiva

around the tooth to be extracted, implants can be

immediately placed at the time of extraction if

there is no active infection present and the esthetic

demands of the site can be met. If the implant was

placed immediately into an extraction site and there

was a gap greater than 1 mm between the implant and

the labial cortical bone, then a graft is placed into the

M.S. Block / Oral Maxillofacial Surg

gap. The technique used is similar to that presented by

Sclar [17].

Mandibular molars

The goals of the graft are a ridge that has ideal

height and width for an implant that will provide an

optimal platform for a molar tooth. At the time of

tooth extraction, an inferior alveolar nerve block

combined with local infiltration into the mucosa

surrounding the mandibular molar is used to provide

anesthesia, hemostasis, and hydropic dissection. A

sulcular incision is made with anterior and posterior

vertical releasing incisions to mobilize a flap for

primary coverage after the graft is placed. With the

full-thickness flap raised, the tooth is extracted,

minimizing bone removal (Fig. 6). If necessary, the

tooth is sectioned to avoid removal of the facial or

lingual cortical bone. The more cortical bone that

remains after extraction, the more predictable the

final width of the ridge. Soft tissue remnants are

removed with a curette. Before placing the graft

material, periosteal releasing incisions are made to

release the flap to allow for a tension-free primary

closure of the extraction site.

The extraction sockets are filled with the graft ma-

terial. Approximately 0.5 to 1 cc of 250 to 1000 mm–

sized particles are used. Molar sites may also require

the labial bone height to be re-established secondary to

severe periodontal disease. The graft is placed and

firmly compacted into the extraction site, re-establish-

ing height and width of the ridge. Excess fluid is

removed from the grafted site with gauze and gentle

pressure, stabilizing the graft for flap closure. The

mucosa flap is closed primarily with 4-0 nonresorbable

sutures. No membranes are necessary because the

periostium is placed over the graft. The avoidance of

a membrane also may decrease incision breakdown or

infection during the healing period. Patients are placed

on antibiotics for 1 week.

Patients are scheduled for panoramic or periapical

radiographs after 12 to 14 weeks to confirm bone

consolidation and plan for the implant placement.

The grafted sites usually appear sufficient in ridge

width for the placement of wide diameter implants

and have sufficient ridge height for the placement of

implants at least 10 mm in length. If the bone

consolidation has reached the level requiring at least

25 NCm of torque to place the implant, then imme-

diate provisionalization can be performed immediate-

ly after implant placement. With more clinical trials

experience, better correlation of the required torque

or seating stability of the implant to long-term suc-

cess will be determined.

Clinical observations that have been encountered by

the author

The primary closure of the molar site heals un-

eventfully; however, there can be small incisional

dehiscences, with small exposure of the graft mate-

rial. In these situations, the patient is encouraged to

gently rinse his or her mouth and avoid aggressive

rinsing until the graft has consolidated or the site has

re-epithelialized. If the patient is careful, then the final

result will not been compromised.

Immediately after release of the flap and pri-

mary closure, the vestibule is partially obliterated.

By 16 weeks, however, the vestibule re-establishes its

original form. The shape of the ridge is usually broad,

with sufficient vertical height for implant placement.

In the author’s experience, the molar sites have

implants placed 16 weeks after tooth extraction and

graft placement.

At the time of implant placement, the ridges

are usually bone hard and resist needle penetration;

however, the larger the defect to be reconstructed—

with a large (�1 cc) mass of graft placed—the softer

the resultant ridge at 4 months. At the time of implant

placement, when a flap is performed, the human

mineralized cancellous bone graft appears similar to

native bone, with small remnants of the original graft

visible. The graft is firm and the drill encounters

substantial resistance, indicating dense bone forma-

tion within the grafted site. This finding has been

confirmed with trephine biopsy.

At the time of implant surgery, the clinical team

may follow a delayed restoration protocol, with gin-

gival coverage and implant exposure after 4 months

for implant integration. The clinical team may also

use a single-staged protocol, with placement of a

provisional, nonfunctional crown on an abutment,

secured to the implant immediately after implant

placement. The final restoration is placed after

4 months of healing.

Maxillary single rooted teeth sites

For single rooted teeth, the surgical technique

is open and does not use primary closure of the

grafted socket to avoid nonesthetic mobilization of

the keratinized gingiva, which is critical in the esthetic

zone of the anterior maxilla. Local anesthesia is

administered in the labial and palatal tissue adjacent

to the tooth to be extracted. A 15-c blade is used to

make a sulcular incision around the single tooth to

be extracted. A periotome instrument (Nobel Biocare)

is used to separate carefully the bone from the labial

surface of the tooth. The tooth root is atraumatically

Clin N Am 16 (2004) 41–63 51

Fig. 5. (A) This 56-year-old woman presented with a draining fistula adjacent to the mesial root of the mandibular left second

molar. She desired eventual replacement of the tooth by a fixed prosthesis. (B) Periapical radiograph of the molar tooth. Note

the large radiolucent lesion involving the bone around the mesial root of the second molar, extending close to the first molar.

(C) After 1 week of antibiotic coverage and oral rinse with diluted chlorhexidine, a sulcular incision with vertical release was

made, and the second molar tooth with the fractured mesial root was extracted. Granulation tissue was removed gently from the

site. (D) Approximately 0.5 cc of human mineralized bone (Puros, Centerpulse, Carlsbad, California) was placed to graft the

defect and reconstruct the missing vertical and horizontal dimensions of the extraction site. The periostium was scored and

the mucosa closed primarily. (E) After 16 weeks for bone consolidation, the patient returned ready for implant placement. Note

the adequate width of the second molar site. (F) A small incision and flap was raised to expose the graft site, which had

consolidated to form a bone hard ridge. (G) An implant was placed requiring more than 25 NCm to place the implant.

(H) Peripaical radiograph of the final restoration 1 year after function. Note the excellent bone consolidation in the previous large

area of bone loss. (I) The final single tooth implant restoration. (Prosthetics by Dr. Emmet Zimmerman.)


removed, taking care to avoid removal of the labial

cortex (Fig. 7). For teeth that are ankylosed, a thin bur

is used to section the tooth and avoid removal of the

labial bone. When the sites have an intact labial

cortex, an implant can be placed, with the axis slightly

palatal to the incisive edge of the planned restoration.

Gaps greater than 1 mm between the implant and the

cortices are grafted with mineralized bone particles. A

provisional restoration is then placed. A removable

Essix-type of temporary (Raintree Essix, Jefferson,

Louisiana) is preferred by the author to modify the

sulcus morphology during the healing period, without

excessive pressure on the palatal tissues.

In most sites, there are labial cortex defects ranging

from a few millimeters to the entire labial cortex. Up

to 1 cc of mineralized bone can be firmly compacted

in these sites to recreate the root-form eminence and to

achieve sufficient labial bulk for the implant and an

esthetic restoration. A piece of collagen (Collaplug,

Centerpulse Dental, Carlsbad, California) is placed

over the site and the gingival margins approximated to

the collagen with a horizontal mattress suture as

Fig. 5 (continued).


described previously by Sclar [17]. An Essix tempo-

rary is placed to preserve the contour of the papilla and

to form a sulcus for the final restoration (Fig. 8).

The Essix temporary is made from a pre-extraction

cast. Before taking an impression, the restorative

dentist creates a small groove on the lingual aspect

of the tooth. The impression is made and poured in

stone, with the groove present on the tooth to be

extracted. The Essix material is chosen for the vacuum

form because of its wear characteristics and decreased

tendency to fragment compared with typical dental

plastic vacuum-form material. The Essix vacuum

Fig. 6. (A) A 48-year-old woman required removal of her maxillary left first premolar. The tooth had chronic pain unresponsive to

root canal and apicoectomy therapy. (B) Before tooth extraction, a presurgical model was used to place an implant analog into the

premolar extraction site. (C) An implant abutment was placed into the analog and prepared on the presurgical model. (D) A

provisional restoration was made using an appropriate shade and form to provide the patient with a tooth form at time of tooth

extraction and implant placement. (E) The occlusal view of the provisional restoration demonstrates a small occlusal hole for

screw access and cement removal. (F) A surgical guide is made from the presurgical model to guide the surgeon for implant

placement. (G) At time of surgery, incisions were made only around the tooth, without extension to adjacent teeth. The tooth was

carefully extracted, avoiding loss of labial cortical bone. The implant was placed using the surgical guide, and a small gap between

the implant and labial bone was grafted with human mineralized bone. (H) The provisional restoration was placed out of occlusion.

(I) The final restoration was placed 4 months after implant placement. (Prosthetics by Dr. Narang Poititet and Dr. Israel Finger.)


form is trimmed to fit over the teeth in the entire arch.

At the time of surgery, the tooth is extracted and the

dentin is removed to the cementoenamel junction.

This procedure leaves the proper shape of the tempo-

rary tooth to place gentle pressure on the papilla and

form the sulcus during the healing period. The patient

leaves the operatory with the tooth replaced. After

1 week, sutures are removed and, if necessary, the

temporary is adjusted to avoid excessive pressure

on the graft site.

Fig. 6 (continued).


After 4 months, a tissue punch is used to remove a

circular piece of gingiva and implants are placed into

the consolidated graft, without a flap. A provisional

restoration can be placed at implant placement so

long as occlusal loading does not occur. Periapical

radiographs are taken sequentially to monitor bone

and implant healing.

Clinical observations that have been encountered by

the author

For single rooted maxillary sites, graft sites healed

with retention of original ridge form without the

presence of infection. The root prominence of the

anterior maxillary sites was re-established even

when there was no labial cortex present at the time

of the graft.

At 16 weeks, grafted sites appeared to be bone

hard and filled with bone, with remnants of the graft

material present on magnified inspection. Subjec-

tively, the resistance to drilling was similar to that

of native edentulous bone. Implants followed a

two-staged implant placement protocol because of

restorative dentist preference and experience or

followed an immediate provisionalization of the

implants at the time of implant placement surgery.

Occasionally, a site had sufficient bone present to

allow for immediate implant placement at the time of

extraction; however, after placement of the implant

slightly palatal to the incisal edge, there was more than

a 1-mm gap between the implant and labial bone. This

gap was grafted with mineralized bone allograft or

xenograft. When the clinician thought that sufficient

seating torque was present at time of implant place-

ment, the implant was immediately provisionalized.

All implants placed into the grafted extraction sites

integrated and were restored with a final cemented

restoration. There were no cases that required addi-

tional grafting at the time of implant placement.

Immediate provisionalization protocol

When it is desired or planned to provide a fixed

provisional in the implant at the time of surgery, it is

suggested to have most of the procedure performed on

diagnostic casts before the surgery (Fig. 9). Before

Fig. 7. (A) A 52-year-old man needed extraction of his maxillary right second premolar. (B) The tooth had severe periodontal

disease from prior trauma. (C) At time of extraction, there was 5 mm of labial bone loss. The two root sockets were surrounded by

thin labial and thin interceptal bone. (D) A graft of human mineralized bone was placed to reconstruct the site and allow for ideal

implant placement. (E) After 4 months, the site was ready for implant placement. (F) Presurgical models were used to plan the

surgery and immediate provisionalization. An analog was placed. (G) An abutment was placed and prepared on the presurgical

model. (H) A provisional crown was formed over the abutment. (I) A surgical guide included a metal tube to guide the surgeon for

an accurate positioning of the implant in regard to the planned restoration. (J) The implant was placed without the need for

incisions. Through access from a 3.5-mm diameter tissue punch, the site was prepared, the implant placed, the abutment placed,

and the provisional restoration relined in the mouth and adjusted to avoid occlusal loading. (K) A panoramic radiograph of the final

restoration. (L) The final restoration in place. (Prosthetics by Dr. Ariel Raigrodski.)


Fig. 7 (continued).


surgery, the restorative dentist obtains diagnostic casts

of the patient. The proposed tooth to be extracted is

removed from the cast. In the laboratory, after plan-

ning the final restoration in either wax, acrylic, or by

experience, an implant analog is placed to proper

depth and secured with cement/glue or stone. A fixed

abutment is prepared on the cast and a guide stent is

made. A provisional crown is made from a hollowed

denture tooth or a hollow crown form, leaving a small

access hole in the cingulum area to allow for cement

washout and to provide access to the abutment. The

occlusion is modified to prevent loading in any

Fig. 8. (A) A 30-year-old woman presented for replacement of her missing left mandibular premolar. (B) A presurgical model was

used to plan the restoration and immediate provisionalization. An analog of this internal connection implant was placed into the

model. (C) An abutment was placed into the analog and prepared. Note the labial dot to insure that the surgeon orients the

abutment correctly. (D) The provisional crown was fabricated on the prepared abutment on the presurgical model. (E) At the time

of surgery, a crestal incision was combined with two conservative vertical release incisions, and the implant was placed according

to the presurgical planning. (F) The previously prepared abutment was placed and screw retained into the implant. (G) A

provisional restoration out of occlusion was cemented with temporary cement. (H) After 8 weeks for this implant system, a final

impression was made, the final abutment was prepared, and a final ceramic crown fabricated. (I) Final crown in place. (Prosthetics

by Dr. Narang Poititet and Dr. Israel Finger.)


movement of the jaws. For the central incisor sites, a

bite-opening appliance is fabricated to prevent occlu-

sal loading.

At the time of surgery, the surgeon orients the

implant similarly to the orientation of the implant

analog in the diagnostic model. The surgeon places

the implant at the correct depth to avoid excessive

countersinking. The abutment is placed and the pro-

visional crown tried in place. If necessary, the provi-

sional crown is modified out of the mouth until

occlusion and fit is passive. The provisional crown

is cemented with temporary cement. Occlusion is

checked to assure no loading. Sutures are placed

if necessary.

The patients are seen weekly until the immediate

effects of surgical intervention are asymptomatic.

After 4 months to allow for integration, the implants

are exposed if not immediately provisionalized. Final

restorations are fabricated using cement retention.

Radiographic evaluation

Immediate implant placement resulted with bone

at or coronal to the first thread of the implant. At the

Fig. 8 (continued).


time of final restoration (4 months after implant

placement), implants had bone at the level of the first

thread, without crestal bone changes more apical than

the first thread. Radiolucency at the crestal or apical

bone levels was not seen. A radiolucent seam was not

found on these implants.

The average mesial crestal bone levels (a negative

value is coronal to the shoulder of the implant and a

positive value is the distance apical to the top of the

shoulder of the implant) were �0.66 F 0.67 mm

(range 0 to �1.27 mm) at implant placement and 0.51

F 0.41 mm (range 0 to�1.91 mm) at final restoration.

Fig. 9. (A) Preoperative view of patient before extraction of remaining mandibular teeth in preparation for placement of four

implants for a fixed/removable prosthesis. (B) After elevation of a full-thickness flap, the teeth were removed and an

alveoloplasty performed. (C) The bone from the alveoloplasty was particulated and placed into the extraction sockets as a graft to

preserve bone height. (D) After 3 months for healing, the patient returned. Note the excellent ridge form before placing implants.

(E) The implants have been placed in the ideal locations. Note the excellent bone healing in the sites previously grafted with

autogenous bone.


The average distal crestal bone levels were �0.48 F0.68 mm (range 0.64 to �1.91 mm) at implant

placement and 0.48 F 0.53 mm (range 0–1.27 mm)

at final restoration. A measurement of 1.27 mm from

the top of the shoulder of the implants correlated to the

level of the first thread of the implant.

Discussion

Patients who are scheduled for extraction of a

tooth desire replacement of the tooth. The traditional

method has been a fixed partial denture based on the

adjacent teeth. Given the success of endosseous

implants, a single tooth implant restoration is a viable

option for the patient. After a tooth is extracted,

however, resorption of the labial cortical bone can

occur, preventing implant placement. In these situa-

tions, adjunctive bone grafting may be necessary,

which increases patient morbidity and expense.

Unpredictable loss of bone following tooth extrac-

tion or extensive bone loss present at the time of tooth

extraction may prevent successful implant placement

or necessitate adjunctive hard or soft tissue grafting.

The use of human mineralized bone to graft osseous

defects immediately after tooth extraction results in

a site that can have an implant placed without the

need for bone grafting using ramus, chin, or other

donor sites.

Long-term results are not presented in this article;

however, the article provides information on a very

promising technique that may benefit patients. In the

author’s short-term experience, the bone heights have


maintained throughout early loading. From that time

forward, bone height is expected to follow conven-

tional crestal bone level patterns.

When confronted with a molar extraction site with

significant bone loss before tooth extraction, the use

of a graft material that will preserve or recreate bone

in the planned implant site is advantageous. The

mineralized bone evaluated in this patient series

resulted in a site that allowed implant placement and

immediate provisionalization with a restoration.

Summary

With limited follow-up, the short-term results

indicate potential for restoration of the extraction

site bone height and width using human mineral-

ized bone, preserving or recreating the site’s bone

bulk for implant placement without adjunctive graft-

ing procedures.

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