The immediate repair of bony defect after infected tooth extraction is subject to considerable debate. The goal is to achieve the optimal residual ridge width resulting in better bone dimension as well as esthetics for later implant placement. As a horizontal bony defect, guided bone regeneration (GBR) is predictable and successful with either non-resorbable or resorbable membranes. However, the most common clinical complication in GBR is an early membrane exposure which may compromise the final results. The technique of platelet-rich fibrin (PRF), developed by Choukroun et al.,1 requires neither anticoagulant nor any other gelling agent such as bovine thrombin. This fibrin network can enhance cell growth, migration, and proliferation.2 In this case report, PRF was applied to the buccal cortical plate dehiscence for further ideal implant placement after extraction of the infected tooth 21 with external root resorption.
A systemically healthy 58-year-old man with the chief complaint of severe mobility of tooth 21 wanted to remove the mobile tooth and then restore the edentulous area with an implant. He mentioned a history of trauma around the premaxilla about 10 years ago. Tooth elongation and persistent pus discharge from the gingival sulci were noted. A periapical radiograph revealed external root resorption and radiolucency with irregular margin around apex (Fig. 1A). The probing depth was exceeding 10 mm over buccal area with pus discharge and bleeding, tooth 21 removal with the GBR procedure was planned. Under local anesthesia, the full-thickness mucoperiosteal flap with two vertical releasing incisions was elevated. Tooth extraction was performed followed by thorough debridement of the infected tissues within the socket (Fig. 1B). Total buccal cortical plate dehiscence was noted. The corticocancelleus grafts (Maxxeus® Dental, Kettering, OH, USA) chopped with PRF membranes were filled in the socket and then the outer surface was covered with PRF membrane (Fig. 1C). Tension-free closure was achieved by using 5-0 nylon. After two weeks, the patient was reappointed for wound inspection and suture removal. The wound healing was uneventful (Fig. 1D). After 3 months, the image of cone beam computed tomography revealed the alveolar ridge preservation with 7.0 mm width in horizontal dimension (Fig. 1E). The dense bone-like tissue bone was demonstrated and the more than 35 Ncm insertion torque noted during implant placement (Fig. 1F).
Figure 1.
(A) Initial periapical x-ray showed external root resorption with periapical radiolucency around the root apex of tooth 21. (B) Clinical photograph demonstrated the totally buccal cortical plate dehiscence of tooth 21. (C) The bony defect was augmented with bone graft and platelet-rich fibrin membrane was used to cover the bone graft. (D) Clinical photograph 3 weeks after treatment. (E) After 3 months, the double-end arrow indicated that the horizontal width reached 7.0 mm on a cone beam computed tomography image. (F) Clinical photograph of re-entry for implantation after 3 months.
Our previous studies have shown that the extraction socket filled with PRF as a sole grafting material could preserve the alveolar ridge.3,4 In this case, marked resorption of the alveolar ridge at both horizontal and vertical directions was shown after tooth extraction. The use of PRF could offer several advantages like promoting soft and hard tissue wound healing due to fibrin bandage and growth factors release such as platelet derived growth factor and transforming growth factor.1 Addition with bone graft materials would be suggested to enhance the effects of PRF for space making in the large bony defect area such as radicular cyst enucleation.5 This could reduce alveolar ridge resorption following tooth extraction and positively influence socket healing over a 3-month period. Taken together, this technique may potentially preserve the alveolar ridge dimension after tooth extraction with buccal cortical plate dehiscence.
Conflicts of interest
The authors report no conflicts of interest related to this study.
References
- 1.Choukroun J., Adda F., Schoeffer C., Vervelle A. PRF: an opportunity in perio-implantology (in French) Implantodontie. 2000;42:55–62. [Google Scholar]
- 2.Tsai C.H., Shen S.Y., Zhao J.H., Chang Y.C. Platelet-rich fibrin modulates cell proliferation of human periodontally related cells in vitro. J Dent Sci. 2009;4:130–135. [Google Scholar]
- 3.Zhao J.H., Tsai C.H., Chang Y.C. Clinical and histologic evaluations of healing in an extraction socket filled with platelet-rich fibrin. J Dent Sci. 2011;6:116–122. [Google Scholar]
- 4.Zhao J.H., Chang Y.C. The alveolar ridge preservation following tooth extraction using platelet-rich fibrin as the sole grafting material. J Dent Sci. 2016;11:345–347. doi: 10.1016/j.jds.2016.08.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Zhao J.H., Tsai C.H., Chang Y.C. Management of radicular cysts using platelet-rich fibrin and bioactive glass: a report of two cases. J Formos Med Assoc. 2014;113:470–476. doi: 10.1016/j.jfma.2011.09.027. [DOI] [PubMed] [Google Scholar]