Abstract

Immediate placement of dental implants (DI) in fresh extraction sockets is associated with remaining voids around the DI and often a partial dehiscence or thin facial alveolar plate. Bioplant HTR synthetic bone (HTR) was used as a ridge preservation/augmentation material in conjunction with this method of DI placement. A 61-year-old white woman requiring extraction of tooth 12 opted for immediate DI placement. HTR was used to fill the remaining socket void and enhance the facial ridge width, and primary closure was attempted with sutures. DI uncovering was performed at about 6 months. Measurements were taken to the nearest 0.5 mm of the internal socket width and total site width at DI placement and uncovering. The internal socket width was essentially maintained (6.8 vs 6.6 mm), and the total ridge width showed a change from 8.7 to 9.1 mm. The results of this case suggest that HTR is a useful adjunct in the placement of immediate DIs for the preservation of ridge width.

USE OF HTR SYNTHETIC BONE AS ANAUGMENTATION MATERIAL IN CONJUNCTIONWITH IMMEDIATE IMPLANT PLACEMENT:A CASE REPORTCLINICALRaymond A. Yukna, DMD, MSAna M. Saenz, DDS, MSMichael Shannon, DDSElizabeth T. Mayer, RDH, BSKEY WORDSDental implantsBone replacement graftsImmediate implant placementRidge preservationAlloplastsRaymond A. Yukna, DMD, MS, is with theDepartment of Periodontics, School ofDentistry, Louisiana State University HealthSciences Center, New Orleans, LA 70119.Address correspondence to Dr Yukna, LSUSchool of Dentistry, Department ofPeriodontics, Box 138, New Orleans, LA70119 (e-mail: ryukna@lsuhsc.edu).Ana M. Saenz, DDS, MS, is formerly withthe Department of Periodontics, School ofDentistry, Louisiana State University HealthSciences Center, New Orleans, LA 70119.Michael Shannon, DDS, is with theDepartment of Prosthodontics, School ofDentistry, Louisiana State University HealthSciences Center, New Orleans, LA 70119.Elizabeth T. Mayer, RDH, BS, is with theDepartment of Periodontics, School ofDentistry, Louisiana State University HealthSciences Center, New Orleans, LA 70119.24 Vol. XXIX/No. One/2003Immediate placement of dental implants (DI) in fresh extraction sockets isassociated with remaining voids around the DI and often a partial dehiscence orthin facial alveolar plate. Bioplant HTR synthetic bone (HTR) was used as a ridgepreservation/augmentation material in conjunction with this method of DIplacement. A 61-year-old white woman requiring extraction of tooth 12 optedfor immediate DI placement. HTR was used to fill the remaining socket void andenhance the facial ridge width, and primary closure was attempted with sutures.DI uncovering was performed at about 6 months. Measurements were taken tothe nearest 0.5 mm of the internal socket width and total site width at DIplacement and uncovering. The internal socket width was essentially maintained(6.8 vs 6.6 mm), and the total ridge width showed a change from 8.7 to 9.1 mm.The results of this case suggest that HTR is a useful adjunct in the placement ofimmediate DIs for the preservation of ridge width.Ttooth extraction can be dettedia ssoc d (an teeth t ac r af rocess p ling d o mIhNTRODUCTIONe boene resorptive andterermoeplval.emen1-3 Prosthofetic reconstruaction andrimental to subsequent implantplacement. The naturaltendency for crestalbone resorption and remodeling, resultingin an apical and lingual loss ofridge anatomy, may result in a site thatis inadequate dimensionally for implantplacement. Alveolar bone lossfollowing tooth loss is an ongoing processbecause of the loss of functionalstimulation, but it is most rapid andsignificant immediately after tooth restructures)becomes more difficult(and often unsatisfactory) when anatomicdeformities in the jaw bone ridgesoccur. Dental implant placement canbe compromised or contraindicated becauseof a lack of proper hard and softtissue contours.3-5To fulfill both functional and aestheticrequirements, it may be necessaryto plan immediate implant placementin concert with procedures thatcontribute to the preservation of ridgewidth and height as well as soft tissueRaymond A. Yukna et alTABLE 1Measurements of extraction socket width at time of extraction and at 6 monthsafter HTR grafting and immediate implant placementUncovering(mm)Preoperative(mm)6.6 6.8ethyl-methacrylate), and calcium hydroxidehas shown effectiveness in treatingperiodontal defects and other oralbone loss problems.17-27 This case reportdescribes the use of HTR graft materialin conjunction with the immediate placementof a dental implant.Mean internalridge widthMean total 9.1 8.7MATERIALS AND METHODSabsence of infection, and the quantityand quality of the adjacent soft andhard tissue. Indications and contraindicationsfor placement of implantsinto extraction sites have been extensivelydocumented.12-16dimensions. Available evidence suggeststhat alveolar bone resorption canbe reduced, at least initially, by surgicaltechniques employed at the time oftooth removal. Socket augmentationtechniques appear to be of benefit inpreserving bone dimensions.6-11 A specific synthetic bone substitute(HTR; Bioplant HTR, Bioplant, Norwalk,Conn) that is a biocompatible microporouscomposite of PMMA (poly-methylmethacrylate),PHEMA (poly-hydroxyl-Successful immediate implantplacement into a fresh extraction sitedepends on proper restorative planning,the health of the adjacent teeth,A 61-year-old white woman presentedto the Louisiana State UniversitySchool of Dentistry with an endodonticfailure and vertical fracture on tooth12, which was treatment planned forextraction and immediate placement ofa dental implant. After obtaining informedconsent, tooth 12 was extractedunder local anesthesia using periotomesin an attempt to preserve facialand lingual bone plates. The socketFIGURE 1. (A-D) Clinical series depicting preoperative appearance, extraction socket, implant placement, and HTR graft placement to fillsocket voids, correct crestal irregularities, and add to facial width. Note apical fenestration also covered with HTR (more HTR addedafter photo taken because it was displaced by flap elevation).Journal of Oral Implantology 25HTR GRAFT WITH IMMEDIATE DENTAL IMPLANTFIGURE 2. (A-D) Clinical series continues with closure of wound, 6-month clinical appearance, uncovering of implant showing increasedbulk on facial, and single crown restoration after 6 months of function. The papillae reflect the general contour of the gingiva in thatposterior segment.was aggressively debrided of soft tissue.Flap elevation was used to gain accessto an existing apical fenestrationand to improve the prospects for primarysoft tissue closure. Measurementswere made with a periodontalprobe of the internal facial-lingualsocket width and the total ridge width.A 4.0 mm diameter 3 13 mm lengthhydroxylapatite-coated cylinder implant(Spline MP-1, Sulzer Dental,Carlsbad, Calif) was placed accordingto standard protocols. HTR 40 syntheticbone was hydrated with socketblood and was placed up to and coronalto the level of the existing socketbony walls and to the area of apicalfenestration. Additional HTR wasplaced on the facial surface to increasethe facial-lingual dimension. A colla-26 Vol. XXIX/No. One/2003gen-bandage (CollaTape, Sulzer Dental)was placed and the flaps coronallypositioned with sutures to achieve primaryclosure. All of these materials areroutinely used in our clinic. Standardpostsurgical information and medicationswere given to the patient.Ten days after implant placement,the patient was evaluated and sutureswere removed. Further evaluations andhygiene visits were made at 1, 2, 6, 9,and 12 months postsurgically. At the6-month appointment the implant wasuncovered, measurements were againmade with a periodontal probe of theinternal facial-lingual socket width andthe total ridge width, the healing abutmentwas connected, and the patientwas referred to the restorative dentist.After 3 weeks of soft-tissue healing,the prosthetic phase of treatment wasbegun.RESULTSThe patient tolerated the procedurewell and was pleased with the restorativeresult. There was no untoward in-flammation, tissue necrosis, or otheradverse events associated with the useof HTR. The implant is functioningwell at 6 months after loading.Table 1 demonstrates the measurementsof the internal socket and totalridge widths at the time of extractionand implant placement and at the6-month uncovering. The internalwidth of the socket was well preserved,and there was a slight increase in thetotal ridge width. The clinical case ispresented in Figures 1-3.FIGURE 3. (A-D) Radiographic series showing initial condition of tooth 12, placement of implant and HTR graft, 6-month postoperativeappearance, and crown in place after 6 months of loading. Slight gap apparent between crown and abutment, which was consideredsatisfactory by prosthodontist.DISCUSSIONThe use of the HTR graft material inconjunction with the placement of animmediate dental implant accomplishedthe treatment goal of preservingthe ridge width and improving therestorability and aesthetics of the site.Immediate dental implant placementoffers the patient a reduction in treatmenttime, and use of the HTR syntheticbone appears to preserve theridge contour and width to improverestorability and aesthetics. The greaterbone volume due to preservation ofridge width and height allowed formore ideal dental implant positioning,which had a direct effect on the easeof fabrication, aesthetic result, and biomechanicsof the subsequent crown.SUMMARY AND CONCLUSIONSocket augmentation with HTR syntheticbone appears to fulfill the purpose of aridge preservation/augmentation materialin conjunction with immediate placementof a hydroxylapatite-coated dentalimplant in a fresh extraction socket. Thisclinical case suggests that immediatedental implant placement in combinationwith HTR grafting is a predictable procedure.A good base for successful functionaland aesthetic prosthetic reconstructionwas obtained with this combinedtherapy.ACKNOWLEDGMENTSThis paper was presented in part at theAAID Annual Meeting, New Orleans,La, in November 2001. The clinical as-Raymond A. Yukna et alsistance of Stephanie Weil and SusanBilliot and manuscript preparationprovided by Julie Breaux are appreciatedand recognized. Treatment of thispatient was supported by a grant fromBioplant, Inc, which provided suppliesand funding for the treatment, and bySulzer Dental, Inc, which provided theHA-coated spline dental implant.REFERENCES1. Atwood DA. Some clinical factorsrelated to the rate of resorption ofresidual ridges. J Prosthetic Dent. 1962;12:441-445.2. Atwood DA. Postextractionchanges in the adult mandible as illustratedby microradiographs of midsagittalsections and serial cephalometricJournal of Oral Implantology 27HTR GRAFT WITH IMMEDIATE DENTAL IMPLANTroentgenograms. J Prosthetic Dent.1963;13:810-824.3. Mecall R, Rosenfeld AL. The in-fluence of residual ridge resorptionpatterns on implant fixture placementand tooth position. Part I. Int J PeriodontRest Dent. 1991;13:109-119.4. Gelb DA. Immediate implantsurgery: three-year retrospective evaluationof 50 consecutive cases. Int JOral Maxillofac Implant. 1993;8:388-399.5. Lazzara RJ. Immediate implantplacement into extraction sites: surgicaland restorative advantages. Int JPeriodont Rest Dent. 1989;9:333-343.6. Marzola C, Filho NH, KawakamiRY, Rodriques CBF, Apelbaum A.Report from Brazil: hard tissue replacementimplants. J Oral Implantol.1992;18:399-405.7. Gross J. Ridge preservation usingHTR synthetic bone followingtooth extraction. Gen Dent. 1995;43:364-367.8. Artzi Z, Tal H, Dayan D. Porousbovine bone mineral in healing of humanextraction sockets. Part I. Histomorphometricevaluations at 9 months.J Periodontol. 2000;71:1015-1023.9. Barboza EP. Localized ridgemaintenance using bone membrane.Implant Dent. 1999;8:167-172.10. Camargo PM, Lekovic V, WeinlaenderM, et al. Influence of bioactiveglass on changes in alveolar process dimensionsafter exodontia. Oral SurgOral Med Oral Path. 2000;90:581-586.11. Lekovic V, Camargo PM, Klok-28 Vol. XXIX/No. One/2003kevold PR, et al. Preservation of alveolarbone in extraction sockets usingbioabsorbable membranes. J Periodontol.1998;69:1044-1049.12. Yukna RA. Clinical comparisonof hydroxyapatite-coated titaniumdental implants placed in fresh extractionsockets and healed sites. J Periodontol.1991;62:468-472.13. Block MS, Kent JN. Placementof endosseous implants into tooth extractionsites. J Oral Maxillofac Surg.1991;49:1269-1276.14. Schwartz-Arad D, Chaushu G.The ways and wherefores of immediateplacement of implants into freshextraction sockets: a literature review. JPeriodontol. 1997;68:915-923.15. Wagenberg BD, Ginsburg TR.Immediate implant placement on removalof the natural tooth: retrospectiveanalysis of 1,081 implants. Compendium.2001;22:399-410.16. Ashman A, Bruins P. Preventionof alveolar bone loss postextractionwith HTR grafting material. OralSurg Oral Med Oral Pathol. 1985;60:146-153.17. Yukna RA. HTR polymergrafts in human periodontal osseousdefects. I. 6-month clinical results. JPeriodontol. 1990;61:633-642.18. Ashman A. Applications ofHTR polymer in dentistry. CompendContin Educ Dent. 1988;9(suppl.):S330-S336.19. Eppley BL, Sadove AM, GermanR. Evaluation of HTR polymer asa craniomaxillofacial graft material.Plast Reconstr Surg. 1990;86:1085-1092.20. Yukna RA. Clinical evaluationof HTR polymer bone replacementgrafts in human mandibular Class IImolar furcations. J Periodontol. 1994;65:342-349.21. Huys LWJ. Replacement therapyand the immediate post-extractiondental implant. Implant Dent. 2001;10:93-102.22. Bolouri A, Haghighat N, FrederiksenN. Evaluation of the effect of immediategrafting of mandibular postextractionsockets with synthetic bone.Compendium. 2001;22:955-966.23. Froum S, Orlowski W. Ridgepreservation utilizing an alloplast priorto implant placementclinical and histologicalcase reports. Pract PeriodontAesthet Dent. 2000;12:393-402.24. Ashman A, LoPinto J. Placementof implants into ridges graftedwith Bioplant HTR synthetic bone: histologicallong-term case history reports.J Oral Implantol. 2000;26:276-290.25. Salman L, Kinney LA. Clinicalresponse of hard tissue replacement(HTR) polymer as an implant materialin oral surgery patients. J Oral Implantol.1992;18:24-28.26. Ashman A. Postextractionridge preservation using a synthetic alloplast.Implant Dent. 2000;9:168-176.27. Boyne PJ. Use of HTR in toothextraction sockets to maintain alveolarridge height. Gen Dent. 1995;43:470-473.