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Options post tooth extraction

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Immediate implantation, spontaneous healing or Ridge Preservation – these are the available options after a tooth has been extracted. Which option is the best when?

Prof. Ronald E. Jung | Switzerland

There is new thinking in implant dentistry, much like the new thinking that occurred with cariology some 50 years ago. Treatment in cariology used to involve the “Extension for prevention” approach: the more hard tooth substance that could be replaced with an amalgam filling, the less that could go wrong. But since the 1960s, dentists have made retention of hard tooth substance their aim. And between 1964 and today, a prevention program has helped reduce the prevalence of caries in Switzerland by over 90 percent. And a similar new thinking is happening today at the “alveolar process” level. Again, retention instead of replacement is the key. At conferences we should no longer be measuring ourselves against those who can regenerate the largest bone defects, but rather we should seek to impress others with our predictable and low-risk procedures. Because alveolar ridge preservation has its part to play in this new approach, it is not just another technique in the treatment repertoire, it is much more.


Three options after tooth extraction

The first decision that the dentist must make: Should I let the extraction socket heal spontaneously, fill it with a bone replacement material or insert an immediate implant? The best procedure depends on different factors in day-to-day clinical practice: tooth location, the condition of the bone and soft tissue, as well as the patient’s general state of health, his or her personal circumstances and financial situation, to name but just a few factors.

It is important that the treatment decision is discussed before the tooth is extracted. Depending on the option, the bone lost during the first four to six months is:

  • 50 % for spontaneous healing1,
  • 56 % for immediate implantation2,
  • 15–20 % for immediate implantation with “gap filling”3, and
  • 15 % for Ridge Preservation4.

When should Ridge Preservation be performed?

In our clinic, Ridge Preservation is always carried out if no implant is placed within the first eight weeks after tooth extraction. There is another approach, however, which involves Ridge Preservation after every tooth extraction, if an implant or bridge restoration is planned. Above all, private practitioners claim that this pre-emptive measure gives them a greater degree of security. The alveolar ridge is usually sufficiently broad at the time of implant placement, and one can verify the quality of the regenerated bone, so this approach is also legitimate.


The right procedure

The tooth should be extracted atraumatically after the soft tissue has been released using a desmotome or scalpel. In general you can say: the gentler, the better. The extraction socket should then be curetted. This step must be performed carefully, as it can help prevent later complications. Using a periodontal probe – and a CBCT scan, if one is available – it is possible to establish whether the buccal socket wall is intact. The procedure depends on this diagnosis.


If at least 50 % of the buccal bone lamella has been resorbed, volume should be gained by contouring. After a flap has been prepared, the bone replacement material is poured into the socket and applied in a buccal direction. A collagen membrane is laid over the graft and ridge to contain the graft and prevent soft tissue invasion. Primary wound closure improves prognosis. The membrane itself does not need to be sutured.

If the buccal lamella is largely intact, the bone replacement material is poured into the socket without flap preparation, and the socket is then sealed – with a disc of collagen matrix Geistlich Mucograft® Seal or with an autologous soft tissue punch graft or a connective tissue palatal harvest graft.

This “sealing” procedure has an advantage over the contouring approach, as the mucogingival border is not displaced. If a collagen matrix is used, which means that no harvest graft needs be taken from the palate, then the procedure is even less invasive. If, however, the soft tissue has to be thickened, an autologous transplant is absolutely necessary.

There is very little convincing evidence for an approach using only bone replacement material, i.e., without a soft tissue transplant, wound closure, membrane or matrix.  A randomized comparative study from our group has shown that, in the event of a Ridge Preservation without a collagen membrane or matrix, even more bone volume is lost than with spontaneous healing (bone material used: beta-tricalcium phosphate with a special coating)4.

Prof. Ronald E. Jung

Prof. Ronald E. Jung | Switzerland

Center for Dental and Oral Medicine
University of Zurich

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Adiv Fenton wrote:

"What if the extracted tooth presents an infection or is removed with a cyst ? In which case would you wait before grafting and how long ? How long would you wait generally before implanting a grafted bone on maxillary and mandibular bone ?"


Ronald Jung wrote:

"Dear Adiv Fenton, thanks for your question. In all the studies we performed, we included cases with chronic periapical pathologies including cysts. In all these cases we performed an alveolar ridge preservation procedure including antibiotics for 5 days. The only contraindication for alveolar ridge preservation are acute infections with Pus. In these cases the acute infection needs to be treated before extraction."

Adiv Fenton wrote:

"Thank you for that precesion.
How long do you recommend to wait before implant insertion on preserved alveolar ridges ? What kind of antibiotics would you give in case of CPP ?"


Ronald Jung wrote:

"Thanks for your question. Usually we wait about 6 months after alveolar ridge preservation before implant placement. Bone is than more matured. As antibiotics we take 3 times 750 mg of a aminopenicillin for 5 days"

Gabriel Rodriguez wrote:

"Dear Dr Jung
When doing ridge preservation, why is BioOss collagen different to BiOss particles?
Is there any histological evidence that shows the difference of new bone formation between the two of them.
Kind Regards"


Ronald Jung wrote:

"Thanks for this question. So far the majority of the studies have used BioOss collagen. We currently run a clinical trial comparing both materials but we haven't got the final results yet. Personally I like the handling better of BioOss Coll for the extraction socket. The graft particle stay better to together and the chance that the particles migrate through the tissues is smaller. "