the best socket preservation tips & techniques for dentists tim kosinski, ms, dds, magd material...

The Best Socket Preservation Tips & Techniques for Dentists

Tim Kosinski, MS, DDS, MAGDMaterial in this seminar is for reference purposes only. This seminar is sold with the understanding that neither any of the authors nor the publisher are engaged in rendering legal, accounting, investment, medical or any other professional service directly through this seminar. Neither the publisher nor the authors assume any liability for any errors or omissions, or for how this seminar or its contents are used or interpreted, or for any consequences resulting directly or indirectly from the use of this seminar. For legal, financial, medical, strategic or any other type of advice, please personally consult the appropriate professional.

Material in this seminar is for reference purposes only. This seminar is sold with the understanding that neither any of the authors nor the publisher are engaged in rendering legal, accounting, investment, medical or any other professional service directly through this seminar. Neither the publisher nor the authors assume any liability for any errors or omissions, or for how this seminar or its contents are used or interpreted, or for any consequences resulting directly or indirectly from the use of this seminar. For legal, financial, medical, strategic or any other type of advice, please personally consult the appropriate professional.

About the Webinar Speaker

The Best Tips & Techniques for Dental ImplantsTimothy Kosinski, MS, DDS, MAGD

www.ExecSense.com © ExecSense, Inc.

• Dr. Timothy Kosinski is an Adjunct Assistant Professor at the University of Detroit Mercy School of Dentistry. He has a private practice in Bingham Farms, MI for the past 26 years. Along with his DDS degree from the University of Detroit Mercy he also has a Mastership in Biochemistry from Wayne State University School of Medicine. Dr. Kosinski is a Diplomate of the American Board of Oral Implantology/Implant Dentistry, the International Congress of Oral Implantologists and the American Society of Osseointegration. He is a Fellow of the American Academy of Implant Dentistry and has received his Mastership and Lifelong Learning and Service Recognition from the Academy of General Dentistry. Dr. Kosinski has received many honors including Fellowship in the American and International College of Dentists and the Academy of Dentistry International. He is a member of OKU and the Pierre Fauchard Academy. Dr. Kosinski was the University of Detroit Mercy School of Dentistry Alumni Association's, “Alumnus of the Year,” Dr. Kosinski serves on the editorial review board of REALITY, the information source for esthetic dentistry. He has published 80 articles on the surgical and prosthetic phases of implant dentistry and was a contributor to the textbooks, Principles and Practices of Implant Dentistry and 2010’s Dental Implantation and Technology. He was featured on Nobelbiocare’s Nobelvision, lectures extensively and has placed over 6500 dental implants.

Slide 2

Overview• Bone grafting is possible because bone tissue, unlike most other tissues, has the

ability to regenerate completely if provided the space into which to grow. As native bone grows, it will generally replace the graft material completely resulting in a fully integrated region of new bone. The biological mechanism that provides a rationale for bone grafting are osteoconduction, osteoinduction, and osteogenesis.

• Our objectives are to create a command of basic bone biology, define microscopic and macroscopic components of bone, recognize the clinical indications and benefits for site grafting, describe the categories of grafting materials, describe the surgical steps and protocols for their use, understand the indications for membrane use and gain confidence to begin elementary grafting procedures.

• To understand microscopic physiology we need to understand the components needed for modeling and remodeling of bone, these include osteoblasts, osteoclasts, osteocytes and the periosteum.

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The Best Socket Preservation Tips & Techniques for DentistsTim Kosinski, DDS


What to Know• Osteoblasts have a mesenchymal cell lineage, they secrete growth factors and

proteins responsible for bone development, they are the cells responsible for bone formation, they process the mineralized “osteoid” matrix of bone, the evolve into osteocytes, which are mature osteoblasts, and they are the bone lining cells.

• Osteoclasts are the cells that resorb bone, they are directed by parathyroid hormone, they secrete acids for bone matrix breakdown, they orchestrate bone rebuilding with osteoblasts and they are found in the Howship’s lacuna.

• Osteocytes are sensory cells for bone strain, they have dendritic processes for chemical communication to the outer surface layers of bone, they secrete platelet derived growth factors, they direct the remodeling sequence, they are “retired” osteoblasts, and they remain in the bone after mineralization occurs.

• The periosteum is the outermost surface of bone, is a thin dense membrane which contain the nerves and blood vessels that nourish the bone, they are the protective barrier in the bone regeneration process and gives rise to the Periosteal osteoblasts.

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Tips & Techniques• There are several types of bone that need to be discussed here. Type I

bone is typically found in the anterior mandible and has a very dense cortical plate.

• Type II bone is typically found in the posterior mandible and also has a thick cortical plate.

• Type III bone is typically found in the anterior maxilla, has a thin cortical plate but is more dense in structure than the posterior maxilla.

• Type IV bone is typically found in the posterior maxilla, has a thin cortical plate and a spongy interior.

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Anatomy to be Considered With Bone Loss• Important anatomy to consider in the oral cavity is the mandibular canal,

the mental foramen and the infra-alveolar nerve which is normally located near the submandibular fossa and below the mylohyoid line.

• Maxillary anatomy to consider are the maxillary sinus, nasal sinus, buccal and nasal fossa

• When bone is loss, bone will shrink apically and lingually or palatally. Socket preservation helps reduce this physiologic bone loss and increases esthetics and function of subsequent prosthetics.

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Bone Characteristics• All skeletal bone demonstrates volume stability over time except

dental alveolar bone because dental alveolus is very labile in the absence of loading.

• Removal of teeth results in; loss of crucial support plates, loss of vascularity to the alveolar process, ultimate bone resorption, crestal bone loss, site collapse where there are this buccal-lingual plates and bone loss on adjacent teeth.

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Advantages of Socket Preservation• Prevention of bone loss after extraction, restoration of the defect back to its

original state, prevention of soft tissue collapse in the extraction site, graft materials sequester integratable bone and allows us to better plan for the restorative future.

• The art of bone grafting consists of guided tissue regeneration, which is a procedure that enables bone and tissue to grow into a desired area.

• The mechanisms of bone regeneration consist of; osteogenesis, which is the ability to create viable bone cell development, osteoinduction, which is the ability to stimulate those cells capable of formulating bone cells, such as bone morphogenic proteins and platelet derived growth factors as a chemical process, and osteoconduction which is a structure that is created to support or scaffold bone development as a physical process.

• Platelet derived growth factors stimulate cell proliferation and healing cascades in bone and other cell types. These are proteins produced from mesenchymal cells, or released by platelets during clotting.

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Review of the Patient’s Health History• Uncontrolled diabetes, cancer, liver diseases, blood dyscrasias, severe alcoholism,

cardiac conditions, smoking and bisphosphonate use all have a common denominator which is compromised wound healing. The body needs a consistent healthy blood supply to assist and encourage healing and a mechanism to avoid putting additional stresses on the body’s system.

• Bisphosphonates are used in medicine to inhibit bone resorption and hence bone turnover and renewal. This reduces serum calcium levels as well. The reason for this anti-osteoclastic or anti resorption effect is the inhibition and/or irreversible cell death of the osteoclasts. Bisphosphonate is readily bound to the mineral crystals on every bone surface and repeated doses accumulate in the bone matrix. During bone remodeling, osteoclasts resorb the bone and ingest the bisphosphonate. Therefore the osteoclasts essentially die.

• Without bone resorption and the concomitant release of bone induction proteins such as bone morphogenetic proteins, the old bone is not removed and new osteoid is not formed. Dead bone results. The osteocytes do not form new bone, osteoblasts do that (rather they act as a mechanoreceptor to maintain the mineral matrix of existing bone). Hypermineralization occurs and sclerosis of the lamina dura results. Bisphosphonates are used for osteoporosis treatment to increase bone mineral density.

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Review of the Patient’s Health History• Bisphosphonates can cause problems in the jaws. Why? The alveolar crest

remodels 10 times the rate of the tibia, the jaw has greater uptake of bisphosphonates and accumulates in a higher concentration. The alveolar bone depends more on osteoclastic bone resorption/remodeling and renewal than any other bone in the adult skeleton. If affected by trauma, such an extraction or an implant placement, the alvelor bone can no longer respond by new bone formation from osteoclastic bone resorption followed by new bone formation and it becomes necrotic.

• Therefore, when a patient begins taking bisphosphonates, the osteoblasts begin to build more bone and this is a good thing. After taking the drug for a while, so much bone gets made that the osteoclasts get destroyed, blood supply becomes compromised and it can’t remodel. This is a bad thing. Ideally we would want the early effects of the drug to enhance bone formation around an implant. The drug has a half life of 15 years.

• The indications for bisphosphonates are osteoporosis, Paget’s disease and metastatic cancers. Intravenous drugs such as Aredia, Zometa, Bonefos and Didronel are very potent. They are used as part of cancer therapy to reduce bone pain and hypercalcemia of the malignancy.

Slide 10



Review of the Patient’s Health History• In rare instances, some individuals receiving IV bisphosphonates for cancer

treatment have developed osteonecrosis of the jaw. Symptoms include pain, swelling or infection of the gums or jaw, gums that do not heal, loose teeth, numbness or a feeling of heaviness in the jaw, drainage and exposed bone.

• Oral bisphosphonates such as Fosomax, Actonel, or Boniva to name a few are also potent, but 1000-10,000 less potent than IV

• So, if your patient is on bisphosphonates, is an invasive surgical procedure a good or bad idea?

• The rules of thumb are: if the patient has an oral route under 5 years of 35mg/week, we are probably safe; Oral use of 70mg/week for under 30 months we are probably safe. Bone density testing may be appropriate. A CTX Serum test has been discussed in the literature as a tool that may help determine bone blood levels. This test theoretically measures the systemic suppression of bone renewal and rate of bone turnover. A rate greater that 150 picograms/ml is normal; 100-150 has a moderate risk and less than 100 value may be a high risk for surgery.

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Tips & Techniques• The local determining factor for implant therapy is bone volume which is

dictated primarily by shape. We want to create an edentulous site with appropriate width and height of bone.

• In evaluating the site we are looking at the height and width of the ridge, any undercuts, the amount of keratinized tissue, proximal spacing, the condition of the remaining teeth and the intra occlusal space.

• The Socket grafting success factors include; atraumatic extractions, minimizing trauma to the surrounding tissue, following successful guidelines for flap design and handling, using principles that avoid disfigurement, and preparing a “bleeding bed” for the material.

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The Current Bone Augmentation Materials• Autogenous bone which is the patient’s own bone harvested from that patient. The

disadvantages of its use are that a second surgical site is needed to harvest the bone, there is normally a limited supply available, and there is the added time needed for the surgical procedures. However, autogenous bone is the “gold standard” since it is osteogenic, osteoinductive and osteoconductive. Osteogenesis occurs when vital osteoblasts originating from the bone graft material contributes to new bone growth with bone growth generated via the other two mechanisms. Osteoinduction involves the stimulation of osteoprogenitor cells to differentiate into osteoblasts that then begin new bone formation. The most widely studied type of osteoinductive cell mediators are BMPs.

• Allografts are materials harvested from another human. These have minimal BMP activity. They are often formulated as mineralized, demineralized or a combination of both. The mineralized material may not resorb and serves as a matrix. There may be some disease transmission concerns with our patients. Allografts may or may not be osteoinductive, but certainly are osteoconductive. Osteoconduction occurs when the bone graft material serves as a scaffold for new bone growth that is perpetuated by the native bone. Osteoblasts from the margin of the defect that is being grafted utilize the bone graft material as a framework upon which to spread and generate new bone. In the very least, a bone graft material should be osteoconductive. Growth factors enhance grafts and are produced using recombinant DNA technology. They consist of either Human Growth Factors or Morphogens (BMPs) in conjunction with a carrier medium, such as collagen.

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The Current Bone Augmentation Materials• Xenografts are materials harvested from another species, such as bovine or

cow bone. The mineralized products have shown not to resorb and they remain radiopaque for years. There are also some concerns about disease transmission. They are strictly osteoconductive materials.

• Alloplastic or synthetic materials have no risk of disease transmission, they scaffold for bone deposition, and they release calcium on resorption. These are strictly osteoconductive materials. There are several Tri calcium phosphate materials on the market today which are outstanding “off the shelf” socket grafting materials. The particles are completely resorbed and there is ingrowth of the granules by bone cells and blood vessels. Bone replaces these materials.

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Membranes• Membranes are placed over a defect and the grafting material to prevent in

growth of unwanted cells such as the gingival connective tissue, epithelium or periodontal ligament remains. Tissue ingrowth will prevent bone formation.

• Resorbable membranes are normally collagen. These maintain space for the graft material which allows better sequestering of PDGF and BMPs from the underlying blood supply, they create a barrier for invasion of unwanted cells, they protect the clot from early contraction and they assist in wound closure .

• Non resorbable membranes are normally at polytetrafluoroethylene materials. They are used primarily when primary closure is not possible

• Tissue grows about 10 times faster than bone. Without a graft, tissue would fill a socket in 2-3 weeks. When using non resorbable membranes we leave them in for a minimum of 2-3 weeks, especially for socket preservation, but the membrane can be left in for 2-3 months depending on the situation.

Slide 15



Complications to Grafting Procedures• Drainage requires opening and evaluating the site; suture breakage

requires an evaluation of the membrane position. If sutures break it is nearly impossible to resuture without causing esthetic damage, if the graft is exposed it needs to be cleaned out and replace.

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Misconceptions1. When you remove a tooth, you should discuss grafting the socket with the patient

regardless of whether an implant will be considered. Grafting reduces vertical and horizontal bone loss and will result in a better esthetic result even with conventional dentistry, such as bridges.

2. Alloplastic materials are easy to use and relatively cost effective. They are radiopaque on initial placement but will look like normal bone in 2-6 months, depending on the patient.

3. Autografts are the gold standard since they are osteogenic, osteoinductive and osteoconductive.

4. Bovine bone is best used to hold a space and may not be the ideal material for future implant placement since you need living bone for an implant to integrate properly.

5. Patients needs informed consent on the type of material you are using to graft a socket. There may be ethical or religious reasons why certain materials are chosen.

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Misconceptions6. Synthetic materials, such as tri calcium phosphate, which is a salt, is an

outstanding choice for simple grafting procedures.

7. Buccal bone must be maintained so atraumatic extractions need to be completed

8. Health histories are important, consider bisphosphonte use by the patient prior to any surgical intervention.

9. Simple grafting procedures are a great service to our patients.

10.There are many materials and procedures available to the profession, so techniques, benefits and risks should be studies.

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the best socket preservation tips & techniques for dentists tim kosinski, ms, dds, magd material...

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