logo 17 • CAMLOG Partner Magazine • March 2018 13 of the tooth, a cervical bone bridge was retained coronal to the defect. The previous formation of a vestibular pedicle mucoperiosteal flap provided an overview of the pathological process on the one hand and protection for the adjacent papillae on the ohter hand. The cystectomy revealed an infected radical cyst which was later histologically confirmed, and which could be enucleated in full. The clinical dimensions of the extracted cyst tissue are shown in Figure 4. To stabilize the clot, a collagen cone (Parasorb, Resorba, Nuernberg) was inserted into the socket without applying pressure (Fig. 5). Since the volume of the bone resorption had already reached such an extent at the time of tooth extraction, adequate reossification of the defect was not expected. This applied in particular to the cancellous alveolar process of the maxilla compared to similar defects in the mandible with a broad cortical bone and higher regeneration potential. For this reason, and because of the presence of an infected cyst, immediate filling of the defect using a socket preservation technique was omitted. In primary wound care, the main objective was therefore soft tissue coverage and healing of the defect to achieve optimal conditions for surgical re-entry for bone augmentation after about 6 weeks. The post-operative course was accompanied with systemic antibiotic treatment (amoxicillin) and a local chlorhexidine gluconate rinse (0.2%) until the sutures were removed after one week. Soft tissue healing and temporary restoration The clinical findings of the anterior tooth segment revealed the expected optical defects after completion of soft tissue healing. Both vertical and transversal losses were apparent when the patient returned. On the other hand, the wound healing was free of irritation, which included complete soft tissue closure of the extraction socket and an inflammation-free gingiva and socket mucosa (Fig. 6). Throughout the entire treatment, starting with tooth extraction and continuing through to the insertion of the implant crown, the patient wore the temporary thermoformed splint (Fig. 7), which was functionally and esthetically acceptable to the patient. To ensure undisturbed soft tissue healing, it is essential to use a temporary restoration which does not apply pressure to the mucous membrane tegument. This implies the use of either splints or adhesive bridges fastened using the acid etching technique. The latter offers the advantage of a greater wearing comfort for the patient (no impairment of the occlusion), however, it does require time-consuming removal and post-operative reattachment to the adjacent teeth for all subsequent treatment steps. In this case, the patient’s needs have to be discussed and taken into account accordingly. Our patient opted for an easy-to-use temporary splint that could be adapted or replaced during the course of the therapy. Bone grafting As was to be expected at the time of the cystectomy and tooth extraction, the extensive bone defect was revealed when the site was reopened, and this had increased even further due to the resorption of the painstakingly preserved cervical bone bridge (Fig. 8). Once again, this shows that any expectations about bone preservation after tooth extraction in the region of the tooth-supporting Fig. 3: Intraoperative site after tooth extraction and cystectomy. Delicate preserved cervical bone bridge. Fig. 4: In toto enucleated radical cyst from the apical region of tooth 11. Fig. 5: Clot stabilization in the cyst defect and the extraction socket using xenogeneic collagen cone. Fig. 6: Clinical defect situation six weeks after tooth extraction. Fig. 8: Expansion of the bony defect with complete resorption of the buccal bone wall prior to bone augmentation. Fig. 7: Thermoformed splint as a long-term temporary restoration throughout the entire treatment. CASE STUDY
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