Dr Imran Nasser treats a significant bony defect and oroantral communication with augmentation protocols that deliver predictable outcomes
Introduction
Though preservation of the natural dentition is the primary goal for all clinicians, extraction is unavoidable in some situations. Restorative options must then be considered, for which implant treatment has become the gold standard. Implant-retained prostheses are associated with improved oral health related quality of life for patients in the short- and long-term.[i] However, this treatment modality is not without potential complications and it’s essential for the clinician to mitigate these.
When a tooth cannot be saved and is indicated for extraction, the condition of the resulting socket must be optimised in preparation for successful implant placement. The extraction procedure is itself linked to both atrophy of the periodontal tissues and resorption of the alveolar bone. As such, augmentation procedures are indicated in order to enhance bone height and volume, in turn creating adequate foundations for a future implant. Ridge preservation techniques, in particular, have been shown to effectively prevent dimensional loss in the alveolar ridge after tooth extraction.[ii]
Case presentation
A female patient presented to the practice as an emergency with pain in the upper left molar, gingival swelling and a bad taste in her mouth. A periapical radiograph and CT scan were taken to assess the pathology. The infection was present on all three walls, having completely destroyed the buccal aspect and perforated the sinus to create a large oroantral communication (OAC). The UL6, therefore, had a hopeless prognosis.
All potential treatment options were discussed with the patient, including the benefits, risks and likely outcomes. There was a risk that extraction of the UL6 would lead to substantial bone loss, requiring hard tissue augmentation, as well as a possibility that odontogenic infection could lead to sinusitis[iii] or infect the graft material, compromising the creation of new bone. Clinician experience and meticulous treatment planning would minimise these risks.
Treatment planning
The clinical photos, periapical radiograph and CT scan provided adequate data to anticipate the size and location of the OAC, affording confidence that it could be sealed effectively.
The UL6 would be extracted atraumatically by sectioning it first. A collagen membrane and allograft would be placed to seal the sinus and build up the buccal bone. An allograft material was favoured in this instance, facilitating implant placement approximately six months post-operatively. While both xenograft and allograft have proven effective in ridge preservation procedures,[iv] [v] allograft exhibits faster bone formation, making it more appropriate for this case.
Post augmentation, a secondary (open) healing approach was preferred in this case to encourage the growth of new soft tissue. The literature shows similar outcomes between primary and secondary closure, though secondary is associated with less initial swelling.[vi]
There were several challenges to consider with the above treatment plan:
- Atraumatic extraction of the tooth would be important but moderately difficult to achieve.
- Enough access would need to be gained to ensure complete removal of the infection.
- Complete debridement of all the granulation tissue would be crucial to ensure no remnants were left behind.
- Regarding the OAC, it was necessary to confirm there was not extensive damage to the sinus membrane.
- The membrane would need to be placed high enough to restore the buccal wall, which was missing all the way beyond the apex.
- When suturing everything closed, it would be vital to ensure that neither the membrane or graft material are compressed in order to protect the volume of the graft.
- It would also be important to ensure no distortion of the mucogingival junction – especially using an open healing technique.
- Closure of the OAC via the socket would be essential.
- It would be vital to ensure the graft material did not extrude into the sinus.
Treatment provision
The UL6 crown was isolated to improve visualisation of the roots. The UL6 was luxated from the centre of the tooth to allow elevation of each individual root. Though typically a flapless procedure, a lack of bone height on the mesial-buccal aspect in this case meant that mesial vertical release was indicated. The incision was positioned to avoid the papilla for improved post-operative healing and aesthetics, and was located away from where the membrane would be placed.
The socket was repeatedly degranulated with a Lucas curette and irrigated with saline to remove the fluid and pus. The author’s protocol concludes with a local antibiotic paste to ensure complete disinfection of the site.
Once the OAC was visible in the mesial-buccal space, the area was sealed with a collagen sponge shaped to size. A second collagen sponge was placed between the graft material and the apices, alongside the Schneiderian membrane.
A MinerOss Blend (BioHorizons Camlog) bone graft was placed, chosen because the combination of particles achieves the density of cortical bone and the revascularisation of cancellous bone for highly effective yet controlled bone remodelling. It is important to ensure that the material is densely packed apically and laterally to achieve volume, while allowing good blood flow around the graft. The material should also be packed only as high as the buccal and palatal bone crest, avoiding the soft tissue layer. Otherwise, there will be loss of bone granules and reduced tissue keratinisation.
Due to the amount of buccal bone loss, a resorbable collagen membrane was placed on the buccal aspect. This collagen membrane was covered upon closing the buccal flap, which was not advanced to avoid any distortion of the mucogingival junction. A dense PTFE membrane – the Cytoplast Titanium-Reinforced PTFE membrane (BioHorizons Camlog) – was then placed on the occlusal aspect and secured with PTFE sutures, which have a high tensile strength to accommodate post-operative swelling and they don’t adhere plaque.
Due to the size of the original OAC, a post-operative CBCT scan was taken to confirm that no grafting material had entered the antrum.
The patient was given post-operative advice, including not brushing the UL4-7 site for two weeks and rinsing with warm salt water during this time.
Review
At the two-week review, the vertical sutures were removed. The sutures securing the PTFE membrane were left in place to ensure stability of the granules for the efficient turnover of bone. The PTFE membrane was also left alone.
The author’s protocols recommend the PTFE membrane to remain in place for four weeks in simple cases, five in moderate cases and six in complex situations. For this case, the membrane was left for five weeks. Upon removal, dense connective tissue had formed underneath, ready to keratinise over the following weeks. The buccal soft tissue had also effectively healed over the collagen membrane to ensure no exposure of this or the bone granules.
At the four-month review, a repeat CBCT demonstrated good healing, good bone turnover and relative density, and adequate ridge dimensions. The sinus had healed completely with an intact sinus floor. The site was ready for implant placement if the patient wished to proceed.
Reflections
This case provides an excellent example of how strict protocols and good products can be utilised to treat significant bony defects. Ridge preservation is an essential skill for clinicians treating compromised sites. For colleagues placing implants in these patients, it is also crucial to have a good understanding of the grafting materials available. I choose from the broad BioHorizons Camlog biomaterial portfolio because the MinerOss Blend and the Cytoplast Titanium-Reinforced PTFE membrane facilitate the ridge preservation protocols I have developed and deliver consistent results. I have found MinerOss Blend, in particular, to be far superior to any other products I’ve used for building bone. For the best outcomes, it’s important to follow the principles of guided bone regeneration (GBR): place the graft material at a site of sound, clean bone; pack it at the right density; and stabilise the bone granules for successful socket preservation.
Further your knowledge about ridge preservation and learn Imran’s protocols in the Ridge Preservation masterclass delivered alongside Dr Minesh Patel. Find out more at https://education.theimplanthub.com/courses/.
For product information from BioHorizons Camlog, please visit https://theimplanthub.com/
Author bio 
Dr Imran Nasser qualified in 2006 from Bristol University and then completed hospital posts in Oral & Maxillofacial Surgery. He completed his Master of the Faculty of Dental Surgery in 2009 and his Master’s degree in Implantology in 2010-2014. For the past four years in succession (2021-2024), Imi has received the accolade of winning the UK Aesthetic Dentistry Awards in Implant & Ceramic categories. He is passionate about sharing his experience and runs various training courses for colleagues.
References
[i] Ali, Z., Baker, S. R., Shahrbaf, S., Martin, N., & Vettore, M. V. (2018). Oral health-related quality of life after prosthodontic treatment for patients with partial edentulism: A systematic review and meta- analysis. Journal of Prosthetic Dentistry, 121(1), 59–68. https://doi. org/10.1016/j.prosdent.2018.03.003
[ii] Avila-Ortiz G, Chambrone L, Vignoletti F. Effect of alveolar ridge preservation interventions following tooth extraction: A systematic review and meta-analysis. J Clin Periodontol. 2019 Jun;46 Suppl 21:195-223. doi: 10.1111/jcpe.13057. Erratum in: J Clin Periodontol. 2020 Jan;47(1):129. doi: 10.1111/jcpe.13212. PMID: 30623987.
[iii] Areizaga-Madina M, Pardal-Peláez B, Montero J. Microbiology of Maxillary Sinus Infections: Systematic Review on the Relationship of Infectious Sinus Pathology with Oral Pathology. Oral. 2023; 3(1):134-145. https://doi.org/10.3390/oral3010012
[iv] Serrano Méndez CA, Lang NP, Caneva M, Ramírez Lemus G, Mora Solano G, Botticelli D
Clinical implant dentistry and related research, 2017, 19(4), 608‐615 | added to CENTRAL: 30 June 2018 | 2018 Issue 6.https://doi.org/10.1111/cid.12490
[v] Atieh MA, Alsabeeha NH, Payne AG, Duncan W, Faggion CM, Esposito M. Interventions for replacing missing teeth: alveolar ridge preservation techniques for dental implant site development. Cochrane Database Syst Rev. 2015 May 28;2015(5):CD010176. doi: 10.1002/14651858.CD010176.pub2. Update in: Cochrane Database Syst Rev. 2021 Apr 26;4:CD010176. doi: 10.1002/14651858.CD010176.pub3. PMID: 26020735; PMCID: PMC6464392.
[vi] Azab M, Ibrahim S, Li A, Khosravirad A, Carrasco-Labra A, Zeng L, Brignardello-Petersen R. Efficacy of secondary vs primary closure techniques for the prevention of postoperative complications after impacted mandibular third molar extractions: A systematic review update and meta-analysis. J Am Dent Assoc. 2022 Oct;153(10):943-956.e48. doi: 10.1016/j.adaj.2022.04.007. Epub 2022 Aug 25. PMID: 36030117.
