Removal of teeth affected by focal infection, sinus lift, bone graft, mounting of implants – Treatment phase I: tartar removal, elimination of dental foci, tooth extraction (Case presentation) (124)

Female patient, aged 62, reported to our clinic with the following complaints:

• She felt her upper right bridge was loose.
• Her rearmost tooth was sensitive and at times decidedly sore on bite.
• She also made mention of foul breath.
• She was intent on having her edentulism restored with implants and was exclusively considering a fixed restoration.

At the first consultation a panoramic radiograph was recorded and the condition of the teeth toroughly assessed.

The first examination revealed that the abutment tooth (no. 17) supporting the upper right bridge was beyond repair due to the great extent of horizontal and vertical bone resorption and was slated for removal. The extensive shadow around the root indicates the great extent of bone resorption.
In the first sitting professional tartar removal was performed. The old bridge was cut at the canine and tooth extraction was performed applying the PRF procedure. The PRF procedure is the most effective and state-of-the-art method that draws on white blood cells, growth factors and cytokines to promote quick wound healing. During the PRF procedure blood is drawn from the patient and centrifuged at low speed with a PRF centrifuge. The fibrin clot thus derived is installed at the sites/cavities of the tooth extractions and the gums are sealed with absorbable sutures above the fibrin clot for better and quicker healing.

 
The benefits of using PRF:

• It has a pain relieving effect with pain as good as resolving the day after PRF.
• Administration of antibiotics is not necessary as the fibrin clot rich in protein cells reduces the risk of infection.
• The fibrin clot keeps the wound moist and promotes the formation of blood vessels (angiogenesis) which is indispensable for proper wound healing and bone formation (ossification).
• The procedure is also applicable with patients on blood diluents.

An upside of absorbable sutures is that no suture removal is necessary with sutures falling out of their own accord in a few weeks’ time.

Following tooth extractions, a removable denture is fabricated to replace extracted teeth for the time of healing. With unilateral edentulism, the fabrication of a denture is rather a delicate matter. Since the denture can only cling on to front teeth, its stability is inadequate for chewing. It is only suitable for smiling and socializing, fit for the “display case”, as it were. We discussed the advantages of a provisional denture with our patient at length and she finally decided against one due to a number of reasons. In her own account, she could not relate even to the thought of a removable denture. She even did some research into the matter to find that the bone and the implant heal way better if no removable denture is mounted on them. She wanted to do her best for the success of healing. Especially in view of the fact that the panoramic radiograph indicated the necessity of a bone graft for mounting implants (bone height was inadequate for the installation of an implant).
The treatment would resume following 3 months’ healing time with a CBCT (Cone beam computed tomography) scan made to examine the healed bone. This is when bone mass is examined and the required kind of bone graft is determined. If bone width is appropriate but bone height is not, then a Sinus lift sufficient. If both bone height and width are insufficient, however, a horizontal and vertical bone augmentation will be necessary (that is, the bone not only needs to be heightened but also to be widened).

 

Bibliography:
Gy. Szabó: Oral and maxillofacial surgery, Semmelweis Kiadó, Budapest 2004.
I. Gera: Periodontology. Semmelweis Kiadó, Budapest, 2009
I. Urbán: Vertical and Horizontal Ridge Augmentation: New Perspectives. Quintessence Publishing, 2017.