Treatment of Two Combined Therapeutic Indications With One Biomaterial

Bone remodeling after tooth extraction leads to progressive alveolar ridge resorption, especially on the buccal aspect, with the midpoint showing nearly twice the loss compared to mesial and distal sites.^1,2 These changes result in a narrower, shorter ridge, often shifted lingually,³ posing challenges for implant-supported restorations. Therefore, planning extraction with a restorative-driven approach is essential to mitigate functional and esthetic complications.

Alveolar ridge preservation (ARP) techniques aim to maintain ridge volume by grafting the socket with bone substitute—autograft, allograft, xenograft, or alloplast—with or without membranes or soft-tissue grafts to facilitate oral tissue regeneration.^4,5 While ARP demonstrates strong evidence for dimensional preservation, biomaterial performance shows moderate evidence due to limited standardization and reporting.⁶ Clinicians must weigh properties and factors such as biocompatibility, resorption, evidence of new bone formation, ease of use, postoperative comfort, cost-effectiveness, and patient preference.⁷ Scaffold design also significantly impacts regenerative outcomes.⁸ Furthermore, pore interconnectivity, particle size, and porosity affect osteoblastic behavior, with collagen-rich scaffolds outperforming highly mineralized ones in bone formation.⁸

The current dental landscape presents multiple options for managing a tooth that is significantly affected by periodontal disease, including extraction with ARP or guided tissue regeneration (GTR). When considering regenerative therapies, repairing compromised periodontal tissues is as important as preserving the alveolar ridge dimension to achieve successful rehabilitation. GTR employs membranes to prevent the ingrowth of epithelial cells into the defect and maintain space for bone regeneration.⁹ However, membrane exposure remains a common complication,¹⁰ especially if the membrane is nonresorbable. One approach to address this issue is through the use of a resorbable xenograft–alloplastic biomaterial (OsteoGen® Plug, Impladent Ltd., impladentltd.com) designed to support key principles of oral tissue regeneration while reducing the risk of membrane collapse. Composed of resorbable calcium apatite and bovine Achilles tendon collagen, the biomaterial mimics the organic and inorganic components of natural bone. Its plug format offers a simple, cost-effective alternative to bone granules and membrane grafts, enhancing clinical manageability.

This case report presents the use of this resorbable bovine collagen and bioactive calcium apatite scaffold as a single biomaterial for ARP in the edentulous site of tooth No. 12 and GTR on the mesial aspect of tooth No. 13.

Case Presentation

A 68-year-old male patient was referred by an endodontist with a diagnosis of symptomatic irreversible pulpitis with normal apical tissues and significant bone loss with furcation involvement on the maxillary left first premolar (tooth No. 12). Due to the periodontal status, rehabilitation with an implant-supported restoration was indicated. Cone-beam computed tomography (CBCT) revealed bone loss on the distal aspect of the affected tooth, measuring 5 mm by 9 mm width and length, respectively, and involving the alveolar bone crest (Figure 1 through Figure 4).

Surgical extraction and regenerative procedures: After a comprehensive review of the patient’s medical and dental history, a clinical examination, and development of an individualized treatment plan, informed consent was obtained. The patient was premedicated with amoxicillin 500 mg, acetaminophen 500 mg, and ibuprofen 600 mg, 30 minutes prior to surgery. Vital signs were recorded and a periapical (PA) radiograph was taken (Figure 5). Local anesthesia was administered via infiltration with articaine hydrochloride 4% with epinephrine 1:100,000 (Septocaine®, Septodont, septodontusa.com).

The existing restoration (No. 12) was sectioned to allow access to the furcation. Both the buccal and palatal roots were extracted using periotomes, elevators, and forceps. The socket was degranulated, and granulation tissue was sent for histopathologic analysis. A PA radiograph confirmed complete removal of the roots. The ARP procedure was performed using the aforementioned resorbable xenograft–alloplastic biomaterial (OsteoGen Plug), which was adapted into the socket (Figure 6). A PA radiograph confirmed the correct biomaterial placement. The site was sutured using polytetrafluoroethylene (PTFE) suture (Figure 7 through Figure 10). Oral hygiene and postoperative instructions were provided to the patient.

At the 1-week follow-up, the patient reported no pain or swelling. The suture was removed and oral hygiene instructions were reinforced.

At 5 months post-extraction, a follow-up CBCT and intraoral scan were taken, and digital implant planning was completed (Figure 11).

Implant placement surgery: No changes were noted in the patient’s health history. The informed consent form was reviewed and signed. The patient was premedicated with amoxicillin 500 mg, acetaminophen 500 mg, and ibuprofen 600 mg, 30 minutes prior to surgery. Local infiltration anesthesia (Septocaine) was administered on the buccal and palatal sides. Using digital implant planning based on the 5-month post-extraction CBCT, a mid-crestal incision and full-thickness flap were performed to gain access to the bone. PA radiographs were taken at multiple steps and an alignment pin was used to confirm depth and angulation, and a bone-level tapered 3.3-mm diameter by 10-mm length implant (Straumann, straumann.com) was placed. The flaps were repositioned to provide improved thickness of keratinized buccal mucosa (Figure 12 through Figure 16).

Oral hygiene and postoperative instructions were provided to the patient. Sutures were removed 1 week later, and oral hygiene instruction was reiterated.

Implant uncovery: Six months after the implant placement, soft-tissue and radiographic assessments were performed (Figure 17). Local infiltration with Septocaine was administered, and a crestal incision was made to expose the previously placed implant. A healing abutment was placed (Figure 18). A PA radiograph confirmed the marginal adaptation of the abutment to the implant (Figure 19). The site was sutured with PTFE, and oral hygiene and postoperative instructions were given to the patient. The patient was followed-up at 2 weeks post–implant uncovery, and the soft tissues appeared healthy (Figure 20 and Figure 21).

The final implant-supported restoration was placed by the restorative dentist 4 weeks after the implant uncovery procedure.

Results

Healing in this case was uneventful, and within 5 months after tooth extraction and ARP, positive findings were observed clinically and radiographically in the extraction site and mesial aspect of tooth No. 13 with presence of periodontal ligament, possibly denoting regeneration. The preserved ridge volume, along with the formation of dense, well-integrated bone, provided an optimal foundation for implant placement. Additionally, the surrounding keratinized soft tissue exhibited stability and healthy architecture, which contributes to predictable esthetic and functional outcomes for implant-supported restoration. These findings highlight the effectiveness of the biomaterial used in the case.

At 16 months follow-up, clinical evaluation revealed preserved ridge volume and stable keratinized soft tissue (Figure 22 and Figure 23). Radiographic analysis confirmed stable bone levels for implant No. 12 and positive radiographic changes of oral regeneration on the mesial of tooth No. 13, including the re-establishment of the periodontal ligament (Figure 24).

Discussion

Periodontal wound healing is a highly dynamic and multifactorial process influenced by a wide range of local, systemic, and environmental factors at both micro and macro levels. It involves the coordinated action of various cell types, biological mediators, cytokines, and extracellular matrix components, all working through overlapping phases of healing. Notably, the early phase plays a crucial role in determining the overall outcome.

To support optimal periodontal wound repair, clinicians should adhere to the PASS principles: ensuring primary wound stability, promoting angiogenesis for adequate blood supply, creating space for cellular repopulation, and maintaining overall wound stability.¹¹ The same principles apply to the clinical goal of maintaining bone and soft-tissue’s volumetric optimal dimensions after tooth extraction. Guided tissue regeneration and alveolar ridge preservation are distinct yet complementary approaches for improving the predictability of oral tissue regeneration procedures. GTR is based on the principle of selective cell repopulation, where a barrier membrane is used to exclude gingival connective tissue and prevent epithelial downgrowth, thereby allowing regenerative cells (such as those from the periodontal ligament, bone, and cementum) to populate the wound site first.¹² On the other hand, ARP focuses on maintaining ridge dimensions following tooth extraction and is supported by strong evidence in this regard, while the clinical performance of biomaterials used (such as autografts, allografts, xenografts, and alloplasts) shows only moderate evidence, primarily due to heterogeneity in study design and material reporting.⁶ In clinical practice, material selection should be guided by a range of factors, including biological and mechanical properties, potential for bone formation, resorption rate, surgical indication, patient comfort, wound healing response, long-term stability, patient satisfaction, and cost-effectiveness.

Despite the promising efficacy of these techniques, membrane exposure, infection, and the need for additional surgical intervention are some of the complications observed.⁷ Additionally, cost-effectiveness should be considered in clinical decision-making from a patient-centered perspective. Defined as the extent to which an intervention produces a favorable outcome relative to its cost, an approach may be deemed less cost-effective if it yields minimal clinical benefit. While not a complication in itself, poor cost-effectiveness can impact continuity of care by introducing additional expenses and contributing to patient dissatisfaction.¹³ Beyond careful case selection and meticulous treatment planning, the clinical choice of biomaterial can mitigate the incidence of complications. The resorbable biomaterial used in this case report, consisting of a bovine Achilles tendon collagen matrix combined with bioactive resorbable calcium apatite crystals, is designed for use in alveolar ridge preservation. In vitro analyses of commercially available ARP products demonstrated that the resorbable xenograft–alloplastic biomaterial exhibits high biocompatibility, supported by assessments of osteogenic potential and scaffold integrity.⁸ Furthermore, a randomized split-mouth controlled clinical trial using CBCT revealed significantly reduced horizontal (1.36 mm) and vertical (0.91 mm) bone loss in sites treated with the biomaterial compared to sites undergoing unassisted socket healing healing.¹⁴

This biomaterial is intended for single use during the augmentation procedure and is designed to be resorbed and replaced by host tissue over time, eliminating the need for membrane removal or secondary interventions. It is important to note that the patient selection criteria for this case included good plaque control, absence of systemic medical conditions, and high patient compliance throughout the treatment and maintenance phases.

This case is novel in that it documents the successful use of a single resorbable biomaterial for two regenerative periodontal therapy indications. Limitations of this case report are that it represents an isolated example and cannot be generalized due to its singular nature and exclusion from a broader case series.

Conclusion

Within the limitations of this case report, the combined xenograft and alloplastic biomaterial plug proved to be an effective, clinically manageable, and cost-efficient alternative to conventional ARP techniques that require multiple components. The material’s ability to support ridge preservation, promote new bone formation, and maintain soft-tissue stability suggests promising potential for simplified regenerative protocols in routine clinical practice. Further multicenter practice-based randomized clinical trials are recommended to validate these findings and assess long-term outcomes.

ACKNOWLEDGMENT

The authors thank the team at The Perio Studio for their support, especially Mrs. Roseann McKenna.

ABOUT THE AUTHORS

Diandra S. Luz, DDS

Harvard School of Dental Medicine, Boston, Massachusetts

Irina F. Dragan, DDS, DMD, MS, eMBA

Adjunct Associate Professor, Periodontology, Tufts University School of Dental Medicine, Boston, Massachusetts; Faculty Member, Harvard School of Dental Medicine, Boston, Massachusetts; Private Practice limited to Periodontology and Implant Dentistry, Boston, Massachusetts

Figures and Images

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Figure 1

Fig 1. Pretreatment intraoral frontal view.

Figure 2

Fig 2. Pretreatment intraoral lateral buccal view.

Figure 3

Fig 3. Pretreatment CBCT coronal view of maxillary left first premolar.

Figure 4

Fig 4. Pretreatment CBCT sagittal view of maxillary left first premolar presenting radiolucency area involving more than two thirds of the root, including the cervical area and alveolar bone crest.

Figure 5

Fig 5. PA radiograph at baseline for extraction of maxillary left first premolar.

Figure 6

Fig 6. The xenograft–alloplastic biomaterial plug was trimmed for optimal socket adaptability.

Figure 7

Fig 7. Maxillary left first premolar extraction. Fresh socket showing preserved soft-tissue contour.

Figure 8

Fig 8. Buccal flap slightly elevated to show good level of vascularity and immediate blood clot formation within the socket.

Figure 9

Fig 9. The xenograft–alloplastic biomaterial plug placed within the socket, and PTFE mattress suture in place.

Figure 10

Fig 10. PA radiograph immediately post-ARP.

Figure 11

Fig 11. Implant 3D positioning in digital planning.

Figure 12

Fig 12. Buccal view of healthy soft tissues 5 months post-extraction of the maxillary left first premolar.

Figure 13

Fig 13. Occlusal view of the alveolar ridge’s preserved volume after extraction.

Figure 14

Fig 14. Occlusal view of the osteotomy for implant placement.

Figure 15

Fig 15. Occlusal view of the ridge immediately after implant placement.

Figure 16

Fig 16. Occlusal view of the suture demonstrating primary closure.

Figure 17

Fig 17. Occlusal view of healthy soft tissues and ridge width 6 months after implant placement.

Figure 18

Fig 18. Buccal view immediately after implant uncovery, abutment placement, and buccal soft-tissue management.

Figure 19

Fig 19. PA radiograph confirming abutment well-fitted to the implant.

Figure 20

Fig 20. Two weeks after implant uncovery, note healthy soft tissues in buccal view.

Figure 21

Fig 21. Occlusal view of ridge width 2 weeks after implant uncovery highlighting improvements on buccal aspect of soft tissue.

Figure 22

Fig 22 and Fig 23. At 16-month follow-up, intraoral occlusal view (Fig 22) and lateral buccal view (Fig 23) showing the screw-retained implant-supported restoration.

Figure 23

Fig 22 and Fig 23. At 16-month follow-up, intraoral occlusal view (Fig 22) and lateral buccal view (Fig 23) showing the screw-retained implant-supported restoration.

Figure 24

Fig 24. At 16-month follow-up, PA radiograph revealing stable crestal bone levels and no pathology detected.