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1. Dentistry news
January 2009
Geistlich Biomaterials Workshop at the European Association of Osseointegration EAO 7th Annual Scientific Meet-
ing, 8 to 20 September 2008, in Warsaw
Management of Extraction Sockets with Anorganic Bone Matrix
Geistlich Bio-Oss® – An Update
After tooth extractions, the physio- the periosteum is recommended, concluded that patients had “a
logical reduction of alveolar bone irrespective of the subsequent significant benefit from receiving
and soft tissues can affect subse- measure. Reduction of the resorp- grafting materials at the time of
quent restorative procedures. This tive process has been demonstrated extraction”6.
applies to both implant-supported when the socket was grafted with Also in a canine study, GBOC was
and conventional restorations. As anorganic bone matrix, without able to preserve the dimension and
the buccal portion of the socket is (Geistlich Bio-Oss®, GBO) or with the contour of the alveolar ridge. The
partially or totally composed of the addition of 0 % collagen (Geistlich authors concluded that “the place-
tooth-related bundle bone, loss of Bio-Oss® Collagen, GBOC). ment of a biomaterial in an extrac-
this tissue will inevitably reduce the In a canine study, grafting of tion socket may promote bone
vertical and horizontal dimensions GBOC resulted in a significant reduc- modeling and compensate, at least
of the alveolar ridge. To compen- tion of the bony invagination over temporarily, for marginal ridge
sate for this resorption, a consider- the former socket, in comparison contraction”.
able number of socket or ridge with a collagen sponge or the
preservation techniques have been untreated control2. In a controlled
Time of implant placement
proposed. clinical study, sockets grafted
Depending on the respective socket
In dogs it was also shown that an with GBO and sutured with split-
or ridge preservation technique the
elevation of flaps can increase the thickness flaps showed a signifi-
amount of soft tissue available for
amount of buccal resorption3. cantly smaller vertical reduction
the subsequent implant insertion
Therefore an atraumatic extraction of the thin buccal plate than
and/or guided bone regenerative
technique without exposure of the ungrafted controls. It was
100%
Benefit of Geistlich Bio-Oss® Collagen
quot;Soft tissue punchquot; benefit
Soft tissue volume
Immediate implant Early implant placement Delayed implant placement
placement
Fig. . Impact of extraction site management technique on soft tissue volume.
2009 PAGE

2. DENTISTRY NEWS January 2009
measure will differ (Fig. ). The (red line in Fig. , recommendation a membrane. In the event of an
appropriate technique is deter- alveolar dehiscence, a biomaterial
Markus Hürzeler, see Fig. ). This
mined, among other parameters, can be used in combination with a
method is indicated when optimal
by the esthetic demands of the collagen membrane (black line in
soft tissue quality is required in the
patient, and the time of implant Fig , technique Dietmar Weng).
esthetic area.
placement (Types to 4 according The therapeutic window can be
to Hämmerle, 2004)4. broadened by placing the implant 2
Presentations at the EAO
In particular, immediate implant to 4 months (Type 3), or more than
placement can be accompanied by 4 months after extraction (Type 4). A specific workshop at the EAO pro-
grafting of GBO particles into the
An advanced approach in the vided more than 400 participants
gaps between implant and bone.
esthetically sensitive area is to with the latest research data in the
When early implant placement 4 to
combine a soft tissue punch tech- field of socket preservation. Two
8 weeks after extraction (Type 2) is
nique with grafting of anorganic renowned clinicians, Prof. Dr. Markus
planned, an advanced free gingival
bone matrix (e.g. GBOC, blue line in Hürzeler and Dr. Dietmar Weng,
graft technique can be used. The
Fig. , by Ronald E. Jung5). Alterna- presented their clinical concepts
graft, which is harvested with a
tively, when the socket is intact, a based on these scientific results and
punch technique, is sutured mini-
biomaterial can be grafted without discussed their practical relevance
mum-invasively into the supra-
with the audience.
closure with a soft tissue graft or
alveolar soft tissues of the socket
References
. Araujo, M., Linder, E., Wennstrom, J. Lindhe, J., (2008) The influence of bio-oss collagen on healing of an extraction socket:
An experimental study in the dog. Int J Periodontics Restorative Dent 28: 23–35.
2. Cardaropoli, G., Araujo, M., Hayacibara, R., Sukekava, F. Lindhe, J., (2005) Healing of extraction sockets and surgically pro-
duced - augmented and non-augmented - defects in the alveolar ridge. An experimental study in the dog. J Clin Periodontol
32: 435–440.
3. Fickl, S., Zuhr, O., Wachtel, H., Bolz, W. Huerzeler, M., (2008) Tissue alterations after tooth extraction with and without surgical
trauma: A volumetric study in the beagle dog. J Clin Periodontol 35: 356–363.
4. Hammerle, C.H., Chen, S.T. Wilson, T.G., Jr., (2004) Consensus statements and recommended clinical procedures regarding
the placement of implants in extraction sockets. Int J Oral Maxillofac Implants 19 Suppl: 26–28.
5. Jung RE, Siegenthaler DW, Hammerle CH. Postextraction tissue management: a soft tissue punch technique. Int J Periodontics
Restorative Dent 2004;24:545–553.
6. Nevins, M., Camelo, M., De Paoli, S., Friedland, B., Schenk, R.K., Parma-Benfenati, S., Simion, M., Tinti, C. Wagenberg, B., (2006)
A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. Int J Periodontics Restorative Dent 26:
9–29.
2009
PAGE 2

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4. DENTISTRY NEWS January 2009
Extraction Site Management Revisited – New Scientific Insights with High
Practical Relevance
the socket may also be an option. maintain the ridge dimensions. In
In beagle dogs fresh extraction all the best results were obtained
sites were treated with one of the with method #4 (GBO plus FGG).
following procedures: Histological evaluation of the
samples will follow.
. Grafting with an anorganic
bone matrix containing
Clinical implications
collagen (Geistlich Bio-Oss®
Collagen GBOC) Staged implant procedures are
2. Grafting with GBOC, in combi- intended to (re-)build the soft tissue
nation with an experimental architecture, and to re-establish
collagen membrane placed interproximal bone after a certain
buccaly into the socket degree of time-related resorption.
3. Socket seal with a free gingi- At the time of early implant inser-
val graft (FGG) tion, after 6 to 8 weeks, minor
4. Untreated control guided bone regenerative tech-
niques will compensate for recent
Histomorphometrical analysis
and previous loss of bone. As it is
showed that neither method was
much more stable and stays in the
able to completely preserve the
site for many years, the best mate-
Markus Hürzeler buccal lamella. However, there was
rial for this purpose is anorganic
Private Practice in Munich, Germany significantly more bone volume
bone matrix (Geistlich Bio-Oss®),
Associate Professor at the Albert-Ludwig with the two GBOC procedures than
not autogenous bone.
University Freiburg, Germany
with the FGG technique, or the
Until the time of implant place-
control.
ment it is important to maintain as
In a further study, preservation of
In the esthetic area clinicians have
much of the soft tissue as possible
the buccal lamina was attempted
to make a choice between fast and
(cf. Fig. , page of this supple-
with the following methods2:
convenient immediate protocols, or
ment). A thick free gingival graft
more predictable, but long-term . Grafting of Geistlich Bio-Oss® from the palate, sutured with
multi-step approaches. Patients (GBO) into the socket, and minimum-invasive sutures, will
tend to prefer the immediate option, over-compensation of the ensure an optimal soft tissue qual-
however in the great majority of buccal aspect with GBO and ity and volume (see case report on
cases, this does not permit predict- Geistlich Bio-Gide® (GBG) the following page). As it will not
able esthetic results. Therefore in
2. Flapless expansion of the prevent the loss of the buccal
our practice we tend to place
buccal lamina lamella, grafting of a biomaterial
implants “early” after 6 to 8 weeks.
3. Grafting of GBO into the into the extraction socket is not
To prevent soft tissue involution
socket, plus buccal over- necessary in connection with an
during this time, we suture a free
augmentation with a connec- early implant protocol. However, in
gingival graft to seal the socket.
tive tissue graft (CTG) and an connection with delayed or late
This measure optimizes soft tissue
FGG protocols grafting of Geistlich
quality for subsequent procedures.
4. Grafting of GBO, plus an FGG Bio-Oss® or Geistlich Bio-Oss
Unpublished data from our group
Collagen® into the socket at the
Again, volumetric results obtained
suggest that, in connection with
time of tooth extraction is a logical
with a CAD technique showed that
delayed implant placement proto-
cols, grafting of biomaterials into approach.
neither method was fully able to
References
. Fickl, S., Hinze, M., Zuhr, O., Wachtel, H., Bolz, W. Hurzeler, M., (2008) Hard tissue alterations after overaugmentation of the
extractions socket. Clin Oral Implants Res 19: 94, poster #239.
2. Fickl, S., Zuhr, O., Wachtel, H., Bolz, W. Huerzeler, M., (2008) Hard tissue alterations after socket preservation: An experimen-
tal study in the beagle dog. . Clin Oral Implants Res 19: –8.
3. Hurzeler, M., Fickl, S., Zuhr, O. Wachtel, H., (2006) Clinical features and shortfalls of immediate implant procedures. Eur J
Esthet Dent 1: 28–40.
2009
PAGE 4

5. DENTISTRY NEWS
January 2009
Fig. 2. Separation of gingival attachment and Fig. 3. Clinical examination shows that the buccal
Fig. . Tooth cannot be preserved due to an
desmodontal ligament is performed with a lamina is not intact, therefore, immediate implant
endodontic complication.
micro-scalpel. placement is not possible on a predictable basis.
Fig. 4. The supra-crestal internal aspect of the Fig. 5. A free gingival graft is removed from the Fig. 6. The graft is sutured into position with
alveolus is deepithelialised with a coarse diamond anterior palate with a tissue punch. microsurgical sutures.
instrument.
Fig. 7. One week after extraction and soft tissue Fig. 8. Occlusal view of the situation one week Fig. 9. Six weeks after extraction the soft tissue
grafting, the site heals without complications. after extraction. volume and condition are perfect for implant
surgery.
Fig. 2. The final restoration shows a natural
Fig. 0. Soft tissue volume is well preserved even Fig. . Intraoperative view at the time of implant
appearance and good soft tissue integration.
in the horizontal dimension. inservtion illustrates loss of the buccal lamina. An
autogenous bone block was grafted, contoured
with GBO, covered with GBG, and then left to heal
for 5 months.
2009 PAGE 5

6. DENTISTRY NEWS January 2009
Simplify your Augmentation – What to Consider at the Time of Extraction
sockets, Cardaropoli and coworkers to handle in comparison with early
(2003) confirmed this observation2. placement after 6 to 8 weeks (cf.
The loss was not prevented by Fig. , page of this supplement).
immediate implant placement, Depending on the defect situa-
either. tion, one the following procedures
If no effective extraction site man- is performed4: When there is no
agement is performed there will be buccal fenestration or bony dehis-
too little soft tissue available for cence, only GBO is grafted into the
subsequent GBR measures. On the socket. One or several gelatine
other hand, 6 to 8 weeks after sponges are placed over the graft
extractions, no hard bone will be material to the level of the soft
available for precise flap surgery tissue margin, and fixed with
required in connection with early criss-cross sutures.
implant placement. As the imma- When there is a dehiscence or fen-
ture intraalveolar bone tissue estration, a collagen membrane
cannot be clearly discerned from (Geistlich Bio-Gide®, GBG) is first
connective tissue, the socket has to placed between the periosteum
be cleaned all the way to the bony and the bone on the buccal aspect,
walls. Now the defect situation does without raising a flap (cf. case report
not differ much from the fresh alve- on the following page). Then GBO is
olus. Futhermore the “bundle bone
Dietmar Weng grafted into the socket, the GBG
effect” will have resorbed major
Private Practice in Starnberg, Germany membrane placed over the graft
parts of the thin buccal bone walls. material, and the membrane cov-
Although part of the buccal bone ered with gelatine sponges. In both
will inevitably be reduced after cases, at the time of implant place-
Clinical implications
extractions this loss can be com- ment, a sufficient amount of buccal
pensated for by socket grafting. For bone will be present due to the
In our practice, we prefer either
this reason, when no immediate socket preservation procedure.
immediate or delayed implant pro-
implant can be placed, we routinely In the event of an immediate
cedures. In the case of a delayed
place a bone substitute material implant placement, grafting and
placement the socket is immedi-
into the fresh socket. After 4–5 implant insertion do not need to be
ately grafted with anorganic bone
months of healing a delayed separated. All gaps between implant
matrix (Geistlich Bio-Oss®, GBO).
implant is inserted into the well
and socket walls, especially on the
After 4-5 months the implant is
preserved site. This separation of buccal aspect, are filled with GBO to
placed. If however, implant place-
the time points of augmentation allow for new bone formation
ment has to be performed at a later
and implant placement reduces beneath the fragile bundle bone. If
time point, there will be no dis-
problems with wound healing, facil- there is a slight dehiscence, GBO
advantages in terms of volume
itates soft tissue management, and and a GBG membrane are placed
shrinkage, since GBO is slowly
simplifies surgical demands. over the implant. Again one or sev-
resorbable. The main benefit is the
As early as in 967, Carlsson and eral gelatine sponges will protect
separation of augmentation (socket
coworkers demonstrated that after graft) and implant placement. The the site from debris and bacteria. If
40 days the buccal bone of human implant is placed into maturing the case was well selected, the
extraction sockets will be almost bone, and the soft tissues are also outcome of this procedure will be
completely resorbed3. In canine more mature and therefore easier successful and predictable.
References
. Araujo, M.G., Wennstrom, J.L. Lindhe, J., (2006) Modeling of the buccal and lingual bone walls of fresh extraction sites
following implant installation. Clin Oral Implants Res 17: 606–64.
2. Cardaropoli, G., Araujo, M. Lindhe, J., (2003) Dynamics of bone tissue formation in tooth extraction sites. An experimental
study in dogs. J Clin Periodontol 30: 809–88.
3. Carlsson, G.E., Thilander, H. Hedegard, B., (967) Histologic changes in the upper alveolar process after extractions with or
without insertion of an immediate full denture. Acta Odontologica Scandinavica 25: 2–43.
4. Weng, D., (2006) “Simplify your augmentation“ - Was bei der Extraktion zu beachten ist, damit die Implantation einfach wird.
Implantologie 14: 355–363.
2009
PAGE 6

7. DENTISTRY NEWS
January 2009
Fig. . Tooth 6 has to be extracted due to Fig. 2. After atraumatic extraction the exact Fig. 3. On the buccal side, a collagen membrane
endodontic problems. Hard and soft tissue amount of bone loss can be investigated with a (Geistlich Bio-Gide®) is placed between the
recession seen on the buccal side. periodontal probe. periosteum and the bone surface (blunt
preparation). No incisions were made.
Fig. 5. On the palatal side the free end of the Fig. 6. A gelatine sponge is positioned over the
Fig. 4. The socket is filled with non-resorbable
membrane is pushed between the periosteum and collagen membrane and fixed with a cross suture.
anorganic bone matrix (Geistlich Bio-Oss®) in order
the bone surface.
to restore the original contour of the alveolar ridge.
Fig. 8. After 0 days the gelatine sponges have
Fig. 7. A second gelatine sponge is placed on the Fig. 9. After 3 weeks the fibrin has almost
disintegrated. Fibrin covers the site and isolated
first cross suture and held in place with a second disappeared, healing is uneventful.
particles of bone substitute material are visible.
cross suture.
Fig. . A flap is raised during implant placement. Fig. 2. Due to the successful preservation of the
Fig. 0. After 3 months, the external ridge
The buccal contour is completely intact. ridge the implant could be placed without
volume proves well preserved.
additional augmentation procedure.
2009 PAGE 7

8. DENTISTRY NEWS January 2009
Concluding remarks
Irrespective of the time point of implant placement, biomaterials from Geistlich have proven to compensate for the loss of bone and soft tissue
after dental extractions. Geistlich Bio-Oss® Collagen should particularly be taken into account for socket and ridge preservation. It has been
shown in animal and clinical research that the management of extraction sockets with this material will preserve the alveolar hard and soft tissue
dimensions to a considerable percentage. Recent still unpublished clinical research will provide further quantitative and three-dimensional
data.
Last but not least, a great number of presentations and case reports by leading clinicians have underlined the high relevance of socket
preservation concepts with biomaterials in daily practice. The presentations of Markus Hürzeler and Dietmar Weng at the EAO provided the
audience with well documented and successful concepts in relation to the time of implant placement.
_______________________________________________________________________________
Please send me more information on
 Geistlich Bio-Oss® First name Surname
 Geistlich Bio-Gide®
 Extraction Sockets
_______________________________________________________________________________
Street Town/ postal code
I would like to order the following reprints
 Weng 2006  Araujo 2008
 Fickl 08  Jung 04 _______________________________________________________________________________
 Nevins 06 Phone e-Mail
Thanks for faxing or mailing us your order: biomaterials@geistlich.ch, Fax +4 4 492 56 39
© Geistlich Biomaterials, CH-60 Wolhusen, www.geistlich.com
Contents
Management of Extraction Sockets with Anorganic Bone Matrix Geistlich Bio-Oss® – An Update …………………………………
Extraction Site Management Revisited – New Scientific Insights with High Practical Relevance …………………………………… 4
Simplify your Augmentation – What to Consider at the Time of Extraction ………………………………………………………… 6
Concluding remarks …………………………………………………………………………………………………………………… 8
Imprint
This publication is sponsored by Geistlich Pharma AG.
The views and opinions expressed within the publication is not the responsibility of Wiley-Blackwell.
The Dentistry News is a new publication offering the dental industry the opportunity to transport workshop presentations,
new scientific findings, press releases etc. quick and easy to selected target group of specialists subscribing to Wiley-Blackwell
journals.
The publication is a loose insert of 4-8 pages which is distributed with selected journals.
Wiley-Blackwell
Copenhagen
Martin Steiniche Nielsen Direct Phone: +45 77 33 33 89
Global Corporate Sales E-mail: mnielsen@wiley.com
2009
PAGE 8