Open Healing: A Minimally Invasive Protocol with Flapless Ridge Preservation in Implant Patients

We aimed to validate the safety and efficacy of the minimally invasive “open healing” flapless technique for post-extraction socket and alveolar ridge preservation, while assessing the alveolar bone changes. The study enrolled (n = 104) patients (0.55 sex ratio), with atraumatic extraction of (N = 135) hopeless teeth, followed by either immediate placement of tissue level implants (N1 = 26), or later stage implant insertion (N2 = 109). No flap was raised in either situation. Post-extraction sockets were filled with deproteinized bovine bone granules and covered by collagen resorbable membrane—left purposely exposed during healing. This yielded an uneventful healing, with sufficient bone formation, while avoiding soft-tissue problems. The need for additional augmentation was assessed clinically and by calibrated CBCT scans at six months, before either loading (N1) or implant insertion (N2). Implant success and survival rate were evaluated at 12-, 24-, and 60-month follow-up control sessions. The inserted implants had a survival rate of 98.5% and a success rate of 94.8% at five-year follow-up. Open healing technique with flapless approach can be favorable for preserving the 3D architecture of the post-extraction socket, as well as the alveolar ridge width and height.

Suppression of Bone Necrosis around Tooth Extraction Socket in a MRONJ-like Mouse Model by E-rhBMP-2 Containing Artificial Bone Graft Administration

Medication-related osteonecrosis of the jaw (MRONJ) is related to impaired bone healing conditions in the maxillomandibular bone region as a complication of bisphosphonate intake. Although there are several hypotheses for the onset of MRONJ symptoms, one of the possible causes is the inhibition of bone turnover and blood supply leading to bone necrosis. The optimal treatment strategy for MRONJ has not been established either. BMP-2, a member of the TGF-β superfamily, is well known for regulating bone remodeling and homeostasis prenatally and postnatally. Therefore, the objectives of this study were to evaluate whether cyclophosphamide/zoledronate (CY/ZA) induces necrosis of the bone surrounding the tooth extraction socket, and to examine the therapeutic potential of BMP-2 in combination with the hard osteoinductive biomaterial, β-tricalcium phosphate (β-TCP), in the prevention and treatment of alveolar bone loss around the tooth extraction socket in MRONJ-like mice models. First, CY/ZA was intraperitoneally administered for three weeks, and alveolar bone necrosis was evaluated before and after tooth extraction. Next, the effect of BMP-2/β-TCP was investigated in both MRONJ-like prevention and treatment models. In the prevention model, CY/ZA was continuously administered for four weeks after BMP-2/β-TCP transplantation. In the treatment model, CY/ZA administration was suspended after transplantation of BMP-2/β-TCP. The results showed that CY/ZA induced a significant decrease in the number of empty lacunae, a sign of bone necrosis, in the alveolar bone around the tooth extraction socket after tooth extraction. Histological analysis showed a significant decrease in the necrotic alveolar bone around tooth extraction sockets in the BMP-2/β-TCP transplantation group compared to the non-transplanted control group in both MRONJ-like prevention and treatment models. However, bone mineral density, determined by micro-CT analysis, was significantly higher in the BMP-2/β-TCP transplanted group than in the control group in the prevention model only. These results clarified that alveolar bone necrosis around tooth extraction sockets can be induced after surgical intervention under CY/ZA administration. In addition, transplantation of BMP-2/β-TCP reduced the necrotic alveolar bone around the tooth extraction socket. Therefore, a combination of BMP-2/β-TCP could be an alternative approach for both prevention and treatment of MRONJ-like symptoms.

Comparison of Alveolar Osteitis (AO) occurrence after impacted mandibular third molar removal with and without post-extraction socket irrigation

Objective: We wanted to see whether impacted third mandibular molar extractions resulted in Alveolar Osteitis if post-extraction socket irrigation was used or not. Methodology: A randomized control experiment on 70 patients study was conducted from July 2019 to January 2020 at Islamabad Dental Hospital's OMFS department. Patients presenting with the mandibular third molars fulfilling the inclusion criteria had their teeth extracted with and without socket irrigation using the computer lottery method. In cases of dry socket, clinical diagnosis was made between the 3rd, 5th, and 7th postoperative days. Results: 70 patients/sockets were evaluated with 35 having been irrigated and 35 non-irrigated. The age range was 16-50years with a mean of 29.49 and most patients were between the 16-35 age group. There were 48.6% males and 51.4% females. Dry Socket was evaluated on the 3rd, 5th, and 7th day between groups (A=irrigation, B=Non-irrigation). On the 3rd postop day, 14 (40%) patients in group A and 15(42.9%) patients were diagnosed as dry Sockets. A similar number of patients in both groups (20%) exhibited symptoms of dry socket on the fifth and seventh postoperative days, as did 5 (14.3 %) in group A, 3 (8.6 %) in group B, and 1(2.9 %t) in group A, all on the fifth postoperative day. Conclusion: On the third, fifth, and seventh postoperative days, there was no significant difference in the result of Alveolar Osteitis between the groups.

The effect of Persea americana Mill. seed extract on inflammatory cells and fibroblast formation in tooth extraction socket healing

Background: Inflammatory cells and fibroblasts have an essential role in the wound healing process. Persea americana Mill. seed categorises as a waste; it contains rich nutrients that can accelerate wound healing activity. Purpose: This study aims to determine the effect of Persea americana Mill. seed against inflammatory cells and fibroblast formation in tooth extraction socket healing. Methods: Ninety-six Sprague Dawley rats had their lower left molars removed. Forty-eight rats tested for inflammatory cells were divided into four groups: negative control group (IC1), positive control group (IC2), Persea americana Mill. seed extract concentrations of 50% (IE1) and 90% (IE2). Another 48 rats used for fibroblast were divided into three groups: the control group (FC1), Persea americana Mill. seed concentrations of 50% (FE1) and 90% (FE2). The gel was applied to the socket under general anaesthesia. Four rats from each group were decapitated for histopathological tissue preparations with Haematoxylin Eosin (HE) staining on the 3rd, 5th and 7th days for inflammatory cells and the 3rd, 5th, 7th and 14th days for fibroblast formation. The preparations for each research were scored under the microscope at 40x magnification. The obtained data was analysed using the Kruska—Wallis and the Mann—Whitney test. Results: A significant decrease (p<0.05) of inflammatory cells in IE2 on the 5th and 7th day. A significant increase (p<0.05) of fibroblast formation between treatment and control groups and no significant difference (p>0.05) between FE1 and FE2 was based on the interval days. Conclusion: Persea americana Mill. seed extract can decrease the inflammatory cells and accelerate the fibroblast formation in tooth extraction socket healing.

A pilot study on immediate loading dental implants

Evolution in the field of dental implantology made the replacement of missing tooth easy and quick. During initial phase of evolution, there was a need of 3 to 6 months of healing period to get teeth on implants but with advancement of technology and research, immediate replacement of missing teeth without waiting period could become a possibility. To access the efficacy of immediate loading in dental implantology using Hexacone® (IHDE DENTAL - Switzerland) dental implant. The objectives were to evaluate pain, infection, recession, loosening of abutment, fracture of implant/crown, de-cementation, peri-implant radiolucency, and marginal bone loss. Five patients (3 male and 2 female) who needed teeth replacement were included in the study. Among 5 patients, 3 patients needed single tooth replacement and the remaining 2 needed segmental replacement. Out of 7 implants 6 implants were placed in the healed bone and 1 was placed in the extraction socket. In case of healed bone, permanent prosthesis were given on 3 day. In case of extraction site, temporary acrylic crown was given on 2 day, which was replaced by permanent prosthesis after 3 month. These patients were evaluated at 7 day, 1 month, 3 months, 6 months and 12 months clinically and radiographically. Infection, prosthetic problems, peri-apical radiolucency, and implant mobility were not observed and marginal bone loss was observed during follow-up periods. On 6 months follow up, 0.5mm and 0.45mm marginal mean bone loss was observed on mesial and distal aspect respectively whereas the same was 1.24mm and 1.14 mm on 12 months follow-up respectively.The immediate loading for dental implants is a successful procedure that decreases the time for the patients to obtain a final restoration satisfying both esthetical and functional problems. Immediately loaded implants survive equally well in extraction socket. No significant difference was seen in survival when implants were placed in healed bone and extraction socket.

Replacement Process of Carbonate Apatite by Alveolar Bone in a Rat Extraction Socket

The objective of this study was to investigate a bone graft substitute containing carbonate apatite (CO3Ap) to analyze bone replacement and the state of bone formation in vitro and in vivo compared with autogenous bone (AB) or control. An osteoclast precursor cell line was cultured with AB or CO3Ap, and morphological analysis using scanning electron microscopy and a tartrate-resistant acid phosphatase activity assay were performed. The right maxillary first and second molars of Wistar rats were extracted and compensated by AB or CO3Ap granules. Following implantation, the bone formation state was evaluated after 3, 5, 7, 14, and 28 days of surgery by micro-computed tomography and immunohistostaining. The osteoclast-like cell morphology was typical with many cell protrusions in the AB and CO3Ap groups. Additionally, the number of osteoclast-like cells formed in the culture increased in each group; however, there was no significant difference between the AB and CO3Ap groups. Five days after tooth extraction, osteoclasts were observed near CO3Ap. The bone thickness in the CO3Ap group was significantly increased than that in the control group and the bone formation in the CO3Ap group increased by the same level as that in the AB group. CO3Ap is gradually absorbed by osteoclasts in the extraction socket and is easily replaced by alveolar bone. The process of bone replacement by osteoclasts is similar to that of autologous bone. By observing the process of bone replacement in more detail, it may be possible to gain a better understanding of the bone formation and control the amount of bone after surgery.

Oxytetracycline-hydrocortisone ointment reduces the occurrence of both dry socket and post-extraction pain after third molar extraction: An observational study

Objectives Dry socket and post-extraction pain are typical discomforts experienced by patients after tooth extraction. In this study, we inserted gauze coated with oxytetracycline-hydrocortisone ointment into the extraction socket immediately after lower third molar extraction and then evaluated the occurrence of dry socket and post-extraction pain compared with gauze non-insertion. Methods This retrospective study was carried out on patients undergoing lower third molar extraction in the Department of Oral Surgery at Shizuoka Prefectural General Hospital in Shizuoka, Japan from November 2018 to October 2019. A comparison was carried out between a gauze-insertion group and a non-insertion group. The occurrence versus non-occurrence of dry socket was determined, and degree of pain was assessed based on a visual analogue scale (VAS) and on patients reporting the number of loxoprofen sodium oral analgesic tablets (60mg/tablet) that they had taken. Dry socket was defined as patient-reported spontaneous pain that did not subside 1 to 3 days postoperatively. Spontaneous post-extraction pain was recorded four times: on the operative day, on the first postoperative day (POD1), on POD3, and during suture removal (POD7). Results The occurrence of dry socket was lower in the gauze-insertion group than in the non-insertion group (0.9%, 2/215 vs. 19.6%, 9/46, p<0.001). The results also showed that both VAS-defined pain level and the number of analgesic tablets taken were lower in the gauze-insertion group than in the non-insertion group on POD3 and POD7. Conclusions and clinical relevance Inserting gauze coated with oxytetracycline-hydrocortisone ointment into the extraction socket immediately after third molar extraction reduces the occurrence of both dry socket and post-extraction pain.

Accelerating Socket Repair via WNT3A Curtails Alveolar Ridge Resorption

Tooth extraction triggers alveolar ridge resorption, and when this resorption is extensive, it can complicate subsequent reconstructive procedures that use dental implants. Clinical data demonstrate that the most significant dimensional changes in the ridge occur soon after tooth extraction. Here, we sought to understand whether a correlation existed between the rate at which an extraction socket heals and the extent of alveolar ridge resorption. Maxillary molars were extracted from young and osteoporotic rodents, and quantitative micro–computed tomographic imaging, histology, and immunohistochemistry were used to simultaneously follow socket repair and alveolar ridge resorption. Extraction sockets rapidly filled with new bone via the proliferation and differentiation of Wnt-responsive osteoprogenitor cells and their progeny. At the same time that new bone was being deposited in the socket, tartrate-resistant acid phosphatase–expressing osteoclasts were resorbing the ridge. Significantly faster socket repair in young animals was associated with significantly more Wnt-responsive osteoprogenitor cells and their progeny as compared with osteoporotic animals. Delivery of WNT3A to the extraction sockets of osteoporotic animals restored the number of Wnt-responsive cells and their progeny back to levels seen in young healthy animals and accelerated socket repair in osteoporotic animals back to rates seen in the young. In cases where the extraction socket was treated with WNT3A, alveolar ridge resorption was significantly reduced. These data demonstrate a causal link between enhancing socket repair via WNT3A and preserving alveolar ridge dimensions following tooth extraction.

A Rare Case of Pyogenic Granuloma in the Tooth Extraction Socket

Pyogenic granuloma (PG) refers to a common, acquired, benign, and vascular tumor that arises in tissues such as the skin and mucous membranes. However, it is extremely rare for PG to arise from an empty socket after tooth extraction. Herein, we describe a rare case of PG that arose from the empty extraction socket of the second molar adjacent to a dentigerous cyst of the left mandibular wisdom tooth in a 57-year-old man. The patient’s second molar was extracted during the same procedure in which the wisdom tooth and cyst were removed. Subsequently, at 42 days after surgery, an exophytic mass was found in the socket of the second molar. An excisional biopsy was performed, and the histopathological diagnosis was PG. Since the PG recurred 90 days after the surgery, a complete excision with bone curettage was performed. During the 12 months of follow-up, there has been no recurrence observed. In conclusion, as tooth extraction is a routine dental practice, clinicians should be aware that PGs can also develop from an extraction socket.