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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 4  |  Issue : 2  |  Page : 89-92

Ridge preservation using demineralized freeze-dried bone allograft and chorion membrane


Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India

Date of Web Publication11-Sep-2015

Correspondence Address:
Rucha Shah
Department of Periodontics, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
India
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Source of Support: Nil., Conflict of Interest: There are no conflicts of interest.


DOI: 10.4103/2231-6027.165101

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  Abstract 

Socket and ridge preservation are emerging as innovative techniques to minimize the postextraction hard and soft tissue collapse. The exaggerated tissue loss in case of compromised sockets often presents an esthetic and prosthetic dilemma to the clinician. This case report shows the potential of demineralized freeze-dried bone allograft (DFDBA) in conjunction with human chorion membrane to manage such a case. A 22-year-old male patient underwent a tooth extraction due to a failed endodontic treatment. A missing buccal wall of socket was managed by using ridge preservation using DFDBA in conjunction with the human chorion membrane. Six months follow-up revealed that the loss of tissue height was 0.36 mm, and loss of tissue width was found to be 2.04 mm. Use of DFDBA in conjunction with human chorion membrane proved to be effective in minimizing soft/hard tissue loss and also helped in some amount of tissue gain.

Keywords: Chorion membrane, demineralized freeze-dried bone allograft, socket preservation


How to cite this article:
Shah R, Thomas R, Mehta DS. Ridge preservation using demineralized freeze-dried bone allograft and chorion membrane. Int J Oral Health Sci 2014;4:89-92

How to cite this URL:
Shah R, Thomas R, Mehta DS. Ridge preservation using demineralized freeze-dried bone allograft and chorion membrane. Int J Oral Health Sci [serial online] 2014 [cited 2019 Nov 21];4:89-92. Available from: http://www.ijohsjournal.org/text.asp?2014/4/2/89/165101


  Introduction Top


The dental socket is formed by the alveolar processes of maxilla and mandible. As the tooth erupts into the oral cavity, it carries along with it the alveolar process. This alveolar process is a tooth-dependent tissue. Following the loss of tooth due to endodontic, periodontal or any other reason, gross internal and external changes take place in its morphology.[1] These changes are manifested as loss of width and height of the residual ridge. The greatest loss is said to occur in the early postextraction period, that is, first 6 months postextraction.[2] The concept of socket preservation was first put forth by Quinn and Kent where they stated that the preservation of alveolar ridge requires immediate graft placement following tooth extraction.[3] However, the term socket preservation was coined by Cohen who defined it as a procedure designed for prosthetic socket maintenance, ridge preservation, and augmentation.[4] In 2007, the Expert Committee on Socket Preservation described the treatment of fresh extraction sockets with intact buccal bone walls as socket preservation, whereas those involving deficient buccal bone walls were classified as ridge preservation.[5] This case report demonstrates the use of demineralized freeze-dried bone allograft (DFDBA) in conjunction with chorion membrane for a case of ridge preservation.


  Clinical Presentation Top


A 22-year-old male patient was referred from the Department of Endodontics for periodontal opinion in relation to #11. The patient had a noncontributory medical history but gave a history of root canal treatment in an upper anterior tooth 4 years ago. On clinical examination, a porcelain fused to the metal crown was observed in relation to #11 [Figure 1]a. The probing depth in relation to #11 was within physiological limits. However, Grade III mobility was observed clinically. Buccally, soft tissue collapse was noted as compared to #22. Radiographic examination revealed complete root resorption and persistent Gutta-percha points in relation to #11. The patient was considered for socket/ridge preservation following extraction of #11. Phase I therapy was completed, a detailed explanation of the surgical procedure was given, and a written consent was obtained from the patient.
Figure 1: (a) Preoperative view. (b) Occlusal view after extraction of #11. (c) Buccal view after extraction of #11. (d) Occlusal view demonstrating missing buccal wall up to apex

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  Case Management Top


The first step in the surgical phase was achieving adequate local anesthesia (lidocaine 2% with adrenaline 1:100,000). This was followed by placement of crevicular incisions around the tooth using number 15c Bard–Parker blade. Atraumatic extraction of the tooth was performed [Figure 1]b, [Figure 1]c. Once the tooth was removed, the socket was thoroughly irrigated using saline. The thickness of gingiva was measured by an endodontic spreader and vernier caliper. It was found to be 0.76 mm. On visual and tactile examination, it was observed that the buccal wall of socket was missing [Figure 1]d. As per the classification proposed by Caplanis et al., an extraction defect sounding four types of defects was observed.[6] The patient was given the option to undergo block grafting or guided tissue regeneration using bone graft and barrier membrane. The risks and benefits of both were also explained to the patient. After understanding both, the patient opted for guided tissue regeneration.

For the same, a vertical releasing incision was given on the distal aspect of #11 extending beyond the mucogingival junction to gain access to the most apical aspect of the extraction socket. This was followed by thorough curettage to remove any persisting inflammatory or granulation tissue. After irrigating and isolating the site, the extraction site was grafted with an allograft (DFDBA) [Figure 2]a (Tata Memorial Tissue Bank, Mumbai) The chorion membrane (Tata Memorial Tissue Bank, Mumbai) of desirable dimensions was trimmed and adapted on the buccal aspect of the socket [Figure 2]b. It was sutured on to the palatal aspect of the socket, and a small portion of the membrane was left exposed at the occlusal part of the extraction socket. The flap was secured back using 4–0 interrupted black silk sutures [Figure 2]c. A temporary restoration was placed as a guide to soft tissue healing and for the esthetics. The extracted tooth is presented in [Figure 2]d.
Figure 2: (a) Placement of demineralized freeze-dried bone allograft into the extraction socket. (b) Placement of chorion membrane to cover extraction socket. (c) Suturing done. (d) Extracted tooth showing complete resorption of root and persistent Gutta-percha points

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Postoperative instructions and medication (diclofenac sodium twice daily for 3 days) were given to the patient. No swelling, pain, or bleeding was observed postoperatively. Suture removal was done at 10 days postoperatively, and the area was irrigated with saline. The patient was recalled after every 15 days for next 2 months and once every month thereafter till the end of 6 months.


  Clinical Outcome Top


Six months after extraction, slight loss of soft tissue was observed. Clinically, the loss of tissue height was 0.36 mm whereas the loss of tissue width was found to be 2.04 mm as measured by a digital vernier caliper [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. The thickness of the gingiva was found to be 0.93 mm as compared to 0.76 mm preoperatively. The soft tissue appeared healthy and completely healed at the end of 4 months. A postoperative intra-oral periapical (IOPA) was obtained and compared to a preoperative IOPA, and it was observed that there was no loss of bone height was observed [Figure 4]a and [Figure 4]b. Interdentally, the bone height as measured in the postoperative IOPA was 2.5 mm short of the crest of adjacent cemento-enamel junction. A Maryland bridge was placed as the final prosthesis as the patient refused to go for bridge or implant retained fixed prosthesis.
Figure 3: (a) Suture removal at 10 days buccal view. (b) Suture removal at 10 days occlusal view. (c) Soft tissue healing at 4-month postoperative buccal view. (d) Occlusal view at 4-month postoperative

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Figure 4: (a) Preoperative intra-oral periapical showing root resorption in relation to #11. (b) Six months postoperative intra-oral periapical showing minimal loss of bone height

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  Discussion Top


The postextraction changes in the alveolus such as loss of hard and soft tissue are often pronounced and hamper the esthetic restoration of a tooth either by a fixed or an implant based prosthesis. In such cases, preplanning and using of dimension preserving techniques such as ridge preservation become prudent. A recent review by Ten Heggeler et al. states that a loss of 2.6–4.6 mm in width and 0.4–3.9 mm in height is possible when an extraction socket is left to heal unaided.[7] When the site is compromised (as in the present case due to missing buccal wall), this loss may be even greater.

DFDBA has both osteoinductive and osteoconductive properties.[8] Placement of the graft not only aids in bone formation but may also physically provide bulk which may prevent tissue collapse. Also, Ten Heggeler et al. have suggested that with respect to socket preservation, the freeze-dried bone allograft performs best.[7] Hence, we used allograft as the graft in our case and were able to prevent loss of hard tissue dimension and some gain in hard tissue and prevented soft tissue collapse.

Fetal allograft membranes such as amnion and chorion have been used for several extra-oral procedures. Chorion membrane is a resorbable fetal derived allograft. It contains collagen Type I, III, IV, V, VI, and several proteoglycans. It also contains several cell adhesion bioactive factors such as fibronectin and laminin. These allografts also have very low immunogenicity.[9] It has also been demonstrated to enhance gingival biotype. Such unique properties make it an interesting new option for application in oral wound healing. Hence, we used this membrane as an alternative to conventional collagen membrane which resulted in excellent esthetics, prevention of tissue loss, and a good biotype postoperatively.

The preservation and enhancement of hard and soft tissue contour of a site indicated for extraction is a key determinant of the future esthetic rehabilitation. In the present case, ridge preservation led to significantly avoid and minimize the loss of hard tissue and soft tissue. Also, an improved gingival biotype was obtained which is more disease-resistant and stable. A limitation of the report is the single case, and no comparison with other type of ridge augmentation techniques has been done. No other socket augmentation reports with chorion membrane were found after a thorough literature search. More controlled long-term studies are required to comment more decisively on the effectiveness of this technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Darby I, Chen S, De Poi R. Ridge preservation: What is it and when should it be considered. Aust Dent J 2008;53:11-21.  Back to cited text no. 1
    
2.
Van der Weijden F, Dell'Acqua F, Slot DE. Alveolar bone dimensional changes of post-extraction sockets in humans: A systematic review. J Clin Periodontol 2009;36:1048-58.  Back to cited text no. 2
    
3.
Quinn JH, Kent JN. Alveolar ridge maintenance with solid nonporous hydroxylapatite root implants. Oral Surg Oral Med Oral Pathol 1984;58:511-21.  Back to cited text no. 3
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4.
Cohen ES, editor. Socket preservation. In: Atlas of Cosmetic and Reconstructive Periodontal Surgery. 1st ed. Philadelphia, PA: Lippincott Williams and Wilkins; 1988. p. 347-63.  Back to cited text no. 4
    
5.
Ackermann KL. Extraction site management using a natural bone mineral containing collagen: Rationale and retrospective case study. Int J Periodontics Restorative Dent 2009;29:489-97.  Back to cited text no. 5
    
6.
Caplanis N, Lozada JL, Kan JY. Extraction defect assessment, classification, and management. J Calif Dent Assoc 2005;33:853-63.  Back to cited text no. 6
    
7.
Ten Heggeler JM, Slot DE, Van der Weijden GA. Effect of socket preservation therapies following tooth extraction in non-molar regions in humans: A systematic review. Clin Oral Implants Res 2011;22:779-88.  Back to cited text no. 7
    
8.
Lohmann CH, Andreacchio D, Köster G, Carnes DL Jr, Cochran DL, Dean DD, et al. Tissue response and osteoinduction of human bone grafts in vivo. Arch Orthop Trauma Surg 2001;121:583-90.  Back to cited text no. 8
    
9.
Niknejad H, Peirovi H, Jorjani M, Ahmadiani A, Ghanavi J, Seifalian AM. Properties of the amniotic membrane for potential use in tissue engineering. Eur Cell Mater 2008;15:88-99.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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   Abstract
  Introduction
   Clinical Present...
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  Discussion
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