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Extraction Site and Ridge PreservationA Peer-Reviewed Publication Written by Dr. Aron Gonshor, BSc, PhD, DDS, FRCD(C), FAO

PennWell is an ADA CERP Recognized Provider

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Educational ObjectivesUpon completion of this course, the clinician will be able to do the following:1. Understand the importance of an

atraumatic extraction technique, ridge and site preservation

2. Understand the pre-operative clinical assessment, and options to consider, for achieving atraumatic tooth extraction

3. Be knowledgeable about the various bone grafting materials available and the results that have been achieved using them

4. Know the steps involved in utilizing the Nu-Mem technique for ridge and site preservation

Abstract It has been estimated that more than 40 million teeth were extracted in 1999. An atraumatic extraction technique, together with ridge and site preservation, is important for function and esthetics following tooth replacement. This is particularly true if an implant is being contem-plated for the extraction site. Atraumatic tooth extraction using the least-invasive procedure possible is the first step. Current techniques used for ridge and site preservation include the use of bone graft materials and/or resorbable membranes. Ideally, at the end of the process the area will be filled with vital, mineralized bone. A combination technique using depro-teinized bovine bone grafting material and a resorbable collagen membrane has been found to produce a consistently preserved alveolar ridge at the site. The addition of a temporary ovate pontic helps to preserve and develop soft tissue contours during healing. Use of an ap-propriate technique preserves alveolar ridge anatomy, facilitates prosthetic management, optimizes function and esthetics, and enables the patient to be treated in a shorter time and with fewer surgical procedures.

Introduction/OverviewExtractions occur primarily as a result of caries, periodontal disease, trauma and crowding, as well as due to other oral pathologies. Caries is endemic and epidemiologically the primary factor in tooth loss in the U.S. population, while advanced periodontal disease is responsible for 30–35% of extractions in those over 40 years of age.1 It has been estimated that in 1999 over 40 million teeth were extracted, of which approximately 25% were surgical extractions involving bone.2

Procedures Number (in millions)

Single extractions 21.44

Soft tissue surgical extractions 7.75

Bony surgical extractions 10.85

Source: ADA. The 1999 Survey of Dental Services Rendered.

Orthodontic extractions overall occur more frequently in people under 21 and most fre-quently it is bicuspids that are extracted. In the under-21s, 57.5% of bicuspid extractions were found in one survey to be due to orthodontic crowding.3 In the case of non-orthodontic extractions, missing teeth result in either a bounded or an unbounded space, which is generally detrimental to oral health. An 81% survival rate was found for teeth adjacent to un-bounded spaces in one study.4 Both bounded and unbounded spaces can result in tilting/tipping of teeth, overeruption, oral hygiene difficulties and secondary problems associated with these changes. Clinically, it is important to replace missing teeth with the best possible option for the patient. An atraumatic extraction technique, with ridge and site preservation at the time of extraction, is important for orthodontic treat-ment outcomes as well as all tooth replacement treatment irrespective of the procedure used for tooth replacement.

Importance of Site Preservation The objectives of an atraumatic extraction tech-nique, as well as ridge and site preservation, are driven by both function and esthetics whether the extraction is for orthodontic purposes or that it will leave a space that should later be restored. Where extractions are for non-orthodontic rea-sons, atraumatic technique and site preservation will lead to a functional and esthetic prosthetic result in the long term. Functionally, removable dentures require the maximum possible bone and soft tissue support for ease of chewing, speaking and denture retention — ridge preser-vation avoids excessive loss of alveolar support and the need for bulky dentures, the latter be-ing cumbersome and unaesthetic. In the case of fixed prostheses, the pontics will be shallower, there will be less recession and bone loss around the abutment teeth, and it will be easier to main-tain periodontal health if the ridge is preserved. Since ridge and soft tissue preservation leaves a soft tissue contour that is more natural, the result will also be more pleasing esthetically. In-creasingly however, implants are being placed, either with immediate or delayed placement, with an estimated two million implants now placed annually.5 If the bony support is poor, or if the soft tissue was severely damaged, then the soft tissue contours and dimensions will also be esthetically displeasing. This has more impli-cations for patients with high lip lines and for the replacement of anterior teeth. Nonetheless, function and esthetics are compromised for all areas of the mouth.

For optimal implant placement, the bone’s height, width, volume and density must fall within certain parameters. In the absence of healed bone of sufficient height or width, either the implant cannot be placed in an optimal posi-tion or a shorter/narrower implant must be used

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or bone grafting must be built into the implant treatment planning and the graft placed prior to implant placement. Secondary bone grafting and ridge augmentation produces a less predict-able result — and involves extra surgery — than primary ridge and site preservation followed by implant placement.6 It has also been found that the peri-implant bone crest height around the implant affects the ability to preserve papil-lae after regeneration between the implant and adjacent teeth.7

Esthetic considerations dictate optimal positioning, especially in the anterior region. If the alveolar ridge has substantially resorbed, an esthetic result is unattainable regardless of the technique used, even if there is sufficient bone height and volume remaining for successful os-seointegration of the implant. In the absence of ridge preservation, it has been found that major changes to the alveolar ridge at the socket site happen in the first year after extraction.8

Atraumatic Tooth ExtractionAtraumatic tooth extraction is the first step in achieving optimal ridge and site preserva-tion. The objectives are removal of the tooth while preserving the soft and hard tissue. Poor extraction technique and/or unanticipated complications can result in soft tissue tears or damage, bone dehiscence around sockets, frac-ture of the labial/buccal cortical plate and bone fragmentation around the socket. It is of utmost importance to preserve the buccal cortical plate in anterior cases to avoid sub-optimal healing and esthetics.

Prior to extracting the tooth, a full clinical and radiographic evaluation must be performed to assess the anatomical relationship of the tooth to adjacent structures, and to determine the tooth’s root morphology. Both single and multi-rooted teeth present potential problems for atraumatic extraction if the roots are especially long and bul-bous. Multi-rooted teeth may also present with di-vergent roots (Figure 1), more roots than standard for that tooth, fused or partially fused roots.

Extraction is achieved using a forceps and/or elevator, selected as indicated for the individ-ual tooth (Figures 2 a, b and 3 a, b, c). In some cases, using a periotome first may help by gently expanding the socket prior to tooth removal. Sectioning of roots in a multi-rooted tooth with divergent roots, or roots with other anatomically unfavorable morphology, may aid atraumatic removal in some cases. If required, sectioning should be performed with minimal invasiveness, avoiding bone removal and soft tissue involve-ment in the procedure. One should remove the minimum tooth substance necessary to section the roots so that the maximum amount of tooth substance remains for elevator and/or forceps positioning and root removal without fractures.

During the extraction, the least-invasive pro-cedure possible should be performed and the use

of flaps should be avoided to minimize trauma.9 Full thickness flaps can destroy the soft tissue architecture at the extraction site and result in soft tissue recession and potential bone loss;10 the vascular supply becomes compromised — limit-ing the future regenerative potential of the site

Figure 1. Upper first molar with divergent roots

Image courtesy of Dr. Bach Le

Figure 2a. Fractured premolar

Figure 2b. Atraumatic premolar forceps extraction

Figure 3a. Elevator use prior to atraumatic premolar extraction

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and leading to soft tissue recession.11 Preserving the papillary architecture leads to more satisfac-tory soft tissue healing and esthetics (Figure 4).

Following tooth removal, the level of bleed-ing from the socket should be checked. Too much bleeding results in hemorrhage and may require the use of hemostats, whereas too little bleeding results in sub-optimal healing. Encouraging adequate bleeding results in osteoblastic cells being introduced into the socket for future bone (re)generation.12

If insufficient bleeding is present, the socket walls should be perforated in several places to promote bleeding. The perforations should be approximately 1.1 mm each, and can be created using a 1.2 mm diameter round bur in a slow handpiece while simultaneously irrigating the site both to remove debris and to prevent heat-related osteonecrosis.

Current Techniques: Ridge and Soft Tissue RegenerationCurrent techniques used for ridge and site pres-ervation include the use of bone graft materials and/or resorbable membranes. The objective of bone grafting materials is to encourage future bone growth into the area. The bone grafting

material acts as an osteoconductor. Ideally, at the end of the process the area will be filled with vital, mineralized bone, with minimal or no bone grafting material remaining.

A variety of materials have been used for bone grafting in sockets, for the purpose of ridge preservation. These include osseous mixtures of donor-retrieved bone particles (au-tografts), allografts and xenograft particulates. Bioabsorbable synthetic sponges consisting of polylactide-polyglycolide acid (Fisiograft®, GHIMAS SpA) have been found to reduce ridge resorption, result in mineralized and well-struc-tured bone growth at the site, and to resorb from the site within 6 months.13 One study found coral granules helped to preserve the alveolar ridge in young patients in the posterior region, but to be ineffective in preserving the ridge over time when used in the anterior maxillary region following trauma.14 The use of titanium membranes over extraction sockets — with or without the use of autogenous bone grafts — has been found to favor ridge preservation.15 Medi-cal-grade calcium sulfate hemihydrate has been found to completely resorb over 4 months and to enable the growth of new trabecular bone.16

Deproteinized bovine bone can be used and has been found to be safe and effective. One study filled sockets with deproteinized bovine bone and then covered the sockets with free gin-gival grafts, harvested with a soft tissue punch. The grafts were found to completely integrate and to produce an esthetic result.17 This however does not develop a soft tissue contour for use around implants. Bovine bone derivatives have also been found to result in bone regeneration both for ridge preservation and at intra-bony periodontal defects, when used alone,18 or in combination with platelet-rich plasma (with and without guided tissue regeneration),19,20,21 and with enamel matrix derivatives.22,23

Bovine porous bone material, in combina-tion with collagen membranes used for guided tissue regeneration at extraction socket sites, has been found to result in more socket bone fill at 6 months than using the bovine bone materials with autologous fibrinogen/fibronectin instead of the collagen membrane.24 A recent study compared the use of deproteinized bovine bone (Bio-Oss®, Osteohealth) in combination with a resorbable membrane (Bio-Gide®, Osteo-health), versus use of the membrane alone dur-ing immediate implant placement. While bone levels were maintained for both groups, the soft tissue margins were more coronal and therefore more favorable esthetically in the group treated with both the bone grafting material and the re-sorbable membrane. The study concluded that the deproteinized bone acted as a membrane support during healing.25 Bone grafting and bar-rier placement have both been found to promote optimal bone remodeling and to be capable of producing an esthetic result. It is important to

Figure 3b. Luxator

Figure 3c. Intact extracted premolar following atraumatic extraction

Figure 4. Preservation of the papillary architecture

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isolate the graft, and resorbable collagen can be used for this. Barrier options include the use of membranes and plugs.

A combination technique developed by Sclar has been found to be effective in preserving the ridge and in preserving/developing an accept-able soft tissue contour at the site.26 Sclar found that use of a deproteinized bovine bone xeno-graft (Bio-Oss®), in combination with a resorb-able collagen membrane (CollaPlug®, Zimmer Dental), produced a consistently preserved al-veolar ridge at the site. This technique has been used for extraction sites that will receive tooth replacement after bone healing, as well as for immediate implant placement sites. In the lat-ter case, the deproteinized bovine bone fills the voids between the newly placed implant and the extraction/implant site. The technique is called the Bio-Col Technique (Bio-Oss® and Colla-Plug®). Recently a product system has become available that still uses Sclar’s technique for ridge preservation, and is called the Nu-Mem System (NuOss™ and RCP/RCT-Resorbable Collagen Plugs and Tapes, ACE Surgical Supply Co., Inc.). Bio-Col and Nu-Mem combine the use of deproteinized bovine bone and resorbable col-lagen membranes for ridge preservation. There are a number of distinct steps in the technique.

Nu-Mem Technique

Step 1.Following atraumatic extraction, the socket is examined for residual debris and to check that the amount of bleeding is appropriate. The deproteinized bovine bone grafting material is then thoroughly packed into the socket up to the level of the crestal bone to ensure maximum bone regeneration (Figures 5 a, b, c).

If an immediate implant is indicated, it should now be inserted. In this case, there will be excess material that will be extruded as the implant is inserted into the site.

Step 2.After the site has been filled to the crestal bone, the barrier material is placed over the graft. The barrier consists of a resorbable collagen mem-brane. The collagen membranes are available as resorbable collagen plugs or tapes.

If the plug is selected, it can be cut in half and the halves placed into the site one piece on top of the other, as required (Figures 6 a, b, c).

It should be noted that Figure 6c shows a situation with a slight disturbance of the papillae following extraction. Ideally, following extraction the papillae should be undisturbed prior to filling of the socket with bone graft material (Figure 7).

Alternatively, the collagen tape can be used and cut into strips before being placed in the socket(s) (Figures 8 a, b). The shape of the strip of tape makes it particularly useful in multiple adjacent sockets.

Figure 5a. Bone graft material

Figure 5b. Graft material packed into the socket

Figure 5c. Graft material up to crestal bone

Figures 6 a,b. Collagen plug

RCP—Cut in half

Figure 6c. Collagen plug placed into socket

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Figure 7. Papillary anatomy maintained

Figures 8a. Resorbable collagen tape

Figure 8b. Collagen tape placed into sockets

Figure 9a. Diagram showing criss-cross and mattress sutures

Figure 9b. Horizontal mattress suture being placed

Figure 10. Resin cantilever temporary bridge, ovate pontic.

Figure 11. Removable prosthesis, ovate pontic design

Figure 12. Prepable abutment

Figure 13a. Pre-operative radiograph

Figure 13b. Post-operative

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The purpose of the barrier membrane is to help hold the grafting material in position and to prevent contamination of the site. It has been found that new bone will develop apical to any debris present.27

Step 3.Following placement of the barrier, the mem-brane or plug can be secured using either mat-tress or criss-cross sutures, or both (Figures 9 a, b). A long-lasting resorbable suture material such as a polygalactin 910 (Vicryl®, Ethicon®; Dexon®, Sherwood Davis and Geck), or a chromic-type suture, will ensure support of the membrane during the initial healing period.

Step 4.The final part of the procedure is the placement of a provisional temporary replacement over the treated extraction site. Placing a provisional that has an ovate pontic shape to simulate the contours of the extracted tooth, encourages soft tissue contouring that will leave a natural appearance when all treatment has been com-pleted. If a temporary bridge can be fashioned using two existing abutments adjacent to the extraction site, or if a bonded temporary pontic can be used, a well-designed ovate pontic can be created (Figure 10). The laboratory can use casts from recent impressions and, in discussion with the dentist, create a pontic shaped and contoured such that it will preserve and help develop soft tissue contours during healing. A similar tech-nique can be used for the replacement tooth on a removable prosthesis that sits over the teeth (Figure 11).

For implants, the use of healing abutments that develop the soft tissue around the implant site has been found to be effective in preserving the soft tissue.28 A prepable abutment may serve a similar function (Figure 12).

The case and diagram in Figure 13 show a pre-extraction radiograph and a post-extraction radiograph. NuOss™ was packed into the socket, followed by placement of a resorbable collagen plug. On the second radiograph, the packed NuOss™ can be clearly seen as well as the ovate pontic and the space between where the resorb-able collagen plug sits (Figures 13 a, b, c).

Using this technique helps preserve both the ridge and the soft tissue for optimal esthetics once a final prosthesis is in place.

Summary As oral health improves, more people are re-taining their teeth and patient expectations are increasing. Increasingly, implants are used to re-place missing teeth. Irrespective of the method used for tooth replacement, preserving the ridge and soft tissue at extraction sites is important for both function and esthetics. Various techniques exist for bone grafting, and for membrane use for guided tissue regeneration. A combination technique using deproteinized bovine bone and a resorbable collagen barrier followed by use of an anatomical temporary tooth replacement has been found to produce consistent results in pre-serving both the ridge and soft tissue contours for the final restoration. As the demand for im-plants continues to grow, the importance of ridge and soft tissue preservation can only increase. Use of an appropriate technique preserves alveolar ridge anatomy, facilitates prosthetic management, optimizes function and esthetics, and enables the patient to be treated in a shorter time with fewer surgical procedures.

Endnotes1 Klinge N, Hultin M, Berglundh T. Peri-

implantitis. Dent Clin N Am. 2005;49:661–676.2 American Dental Association. The 1999 Survey

of Dental Services Rendered.3 McCaul LK, Jenkins WM, Kay EJ. The

reasons for the extraction of various tooth types in Scotland: a 15-year follow up. J Dent. 2001;29(6):401–407.

4 Aquilino SA, et al. Ten-year survival rates of teeth adjacent to treated and untreated posterior bounded edentulous spaces. J Prosthet Dent. 2001;85(5):455–460.

5 Klinge N, Hultin M, Berglundh T. Peri-implantitis. Dent Clin N Am. 2005;49:661–676.

6 Anson D. Maxillary anterior esthetic extractions with delayed single-stage implant placement. Compend Contin Educ Dent. 2002;23(9):829–830, 833–836, 838.

7 Choquet V, Hermans M, et al. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol. 2001;72(10):1364–1371.

8 Schropp L, Wenzel A, et al. Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent. 2003;23(4):313–323.

9 Zeren KJ. Minimally invasive extraction and immediate implant placement: the preservation of esthetics. Int J Periodontics Restorative Dent. 2006;26(2):171–181.

10 Kan JY, Rungcharassaeng K, et al. Flapless anterior implant surgery: a surgical and prosthodontic rationale. Pract Periodontics Aesthet Dent. 2000;12(5):467–474.

11 Sclar AG. Preserving alveolar ridge anatomy

Figure 13c. Post-operative

NuOss™ insocket

Radioluscency where resorbable collagen

has been placedOvatepontic

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following tooth removal in conjunction with immediate implant placement. The Bio-Col technique. Atlas Oral Maxillofac Surg Clin North Am. 1999;7(2):39–59.

12 Sclar AG. Preserving alveolar ridge anatomy following tooth removal in conjunction with immediate implant placement. The Bio-Col technique. Atlas Oral Maxillofac Surg Clin North Am. 1999;7(2):39–59.

13 Serino G, Biancu S. Ridge preservation following tooth extraction using a polylactide and polyglycolide sponge as space filler: a clinical and histological study in humans. Clin Oral Implants Res. 2003;14(5):651–658.

14 Sandor GK, Kainulainen VT, et al. Preservation of ridge dimensions following grafting with coral granules of 48 post-traumatic and post-extraction dento-alveolar defects. Dent Traumatol. 2003;19(4):221–227.

15 Pinho MN, Roriz VL, et al. Titanium membranes in prevention of alveolar collapse after tooth extraction. Implant Dent. 2006;15(1):53–61.

16 Guarnieri R, Aldini NN, et al. Medical-grade calcium sulfate hemihydrate (surgiplaster) in healing of a human extraction socket—histologic observation at 3 months: a case report. Int J Oral Maxillofac Implants. 2005;20(4):636–641.

17 Jung RE, Siegenthaler DW, Hammerle CH. Postextraction tissue management: a soft tissue punch technique. Int J Periodontics Restorative Dent. 2004;24(6):545–553.

18 Scheyer ET, Velasquez-Plata D, et al. A clinical comparison of a bovine-derived xenograft used alone and in combination with enamel matrix derivative for the treatment of periodontal osseous defects in humans. J Periodontol. 2002;73(4):423–432.

19 Lekovic V, et al. Comparison of platelet-rich plasma, bovine porous bone mineral, and guided tissue regeneration versus platelet-rich plasma and bovine porous bone mineral in the treatment of intrabony defects: a reentry study. J Periodontol. 2002;73(2):198–205.

20 Camargo PM, et al. A reentry study on the use of bovine porous bone mineral, GTR, and platelet-rich plasma in the regenerative treatment of intrabony defects in humans. Int J Periodontics Restorative Dent. 2005;25(1):49–59.

21 Camargo PM, Lekovic V, et al. Platelet-rich plasma and bovine porous bone mineral combined with guided tissue regeneration in the treatment of intrabony defects in humans. J Periodontal Res. 2002;37(4):300–306.

22 Scheyer ET, Velasquez-Plata D, et al. A clinical comparison of a bovine-derived xenograft used alone and in combination with enamel matrix derivative for the treatment of periodontal osseous defects in humans. J Periodontol. 2002;73(4):423–432.

23 Pietruska MD. A comparative study on the use of Bio-Oss and enamel matrix derivative (Emdogain) in the treatment of periodontal bone

defects. Eur J Oral Sci. 2001;109(3):178–181.24 Vasilic N, Henderson R, et al. The use of bovine

porous bone mineral in combination with collagen membrane or autologous fibrinogen/fibronectin system for ridge preservation following tooth extraction. J Okla Dent Assoc. 2003;93(4):33–38.

25 Cornelini R, Cangini F, et al. Deproteinized bovine bone and biodegradable barrier membranes to support healing following immediate placement of transmucosal implants: a short-term controlled clinical trial. Int J Periodontics Restorative Dent. 2004;24(6):555–563.

26 Sclar AG. Preserving alveolar ridge anatomy following tooth removal in conjunction with immediate implant placement. The Bio-Col technique. Atlas Oral Maxillofac Surg Clin North Am. 1999;7(2):39–59.

27 Ibid.28 Wheeler SL, Vogel RE, Casellini R. Tissue

preservation and maintenance of optimum esthetics: a clinical report. Int J Oral Maxillofac Implants. 2000;15(2):265–271.

Author Profile

Dr Aron Gonshor, BSc, PhD, DDS, FRCD(C), FAODr. Aron Gonshor is a Maxillofacial Surgeon prac-ticing in Montreal, Canada. He received his PhD in Neurophysiology in 1974, his DDS in 1975, and his Maxillofacial specialty at the Montreal General Hospital — all from McGill University.

He has published extensively on implant therapy, PRP and related topics, and has been a clinical consultant to ACE Surgical Supply Co., helping with the development of their RBM-surfaced implant systems. He has lectured throughout North and South America, Europe and the Far East, covering topics related to im-plant rehabilitation, PRP therapy and wound care, as well as bone graft reconstruction.

A past president of the Canadian Associa-tion of Oral and Maxillofacial Surgeons, he is a fellow of the Royal College of Dentistry and served for 10 years as a director of the Academy of Osseointegration.

DisclaimerThe author of this course is a clinical consultant for the providers of the unrestricted educational grant for this course.

Reader FeedbackWe encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at www.ineedce.com.

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Questions

1. It has been estimated that in 1999, more than _________ teeth were extracted.a. 20 millionb. 30 millionc. 40 milliond. 50 million

2. 57.5 percent of bicuspids extracted in under-21s were due to _________.a. Cariesb. Orthodontic crowdingc. Traumad. None of the above

3. The objective of an atraumatic extraction is _________.a. Removal of the toothb. Preservation of bonec. Preservation of soft tissued. All of the above

4. The objectives of ridge and site preservation are driven by _________.a. Functionb. Aestheticsc. a and bd. None of the above

5. Soft-tissue contours and dimension will be aesthetically displeasing if _________.a. Bony support is poorb. Soft tissue was severely damaged during

extractionc. The patient is over 21d. a and b

6. An estimated _________ implants are placed annually.a. One millionb. Two millionc. Three milliond. Five million

7. For optimal implant placement, the _________ must fall within certain parameters.a. Bone heightb. Bone widthc. Bone volume and densityd. All of the above

8. Secondary bone grafting _________.a. Produces less predictable results b. Involves an extra surgeryc. Is quicker than primary bone graftingd. a and b

9. Poor extraction technique can result in _________.a. Soft tissue damageb. A fracture of the buccal cortical platec. Bone fragmentationd. All of the above

10. A _________ can be used to gently expand the socket prior to tooth extraction. a. Periotomeb. Scalpelc. Polishing burd. All of the above

11. In the case of multi-rooted teeth with divergent roots, _________.a. The patient must always be referred to

a specialistb. Sectioning the roots may aid

atraumatic extractionc. The patient will always need suturesd. All of the above

12. Sectioning of multi-rooted teeth should _________.a. Be minimally invasiveb. Avoid removing bonec. Remove the minimum amount of tooth

substance necessaryd. All of the above

13. Soft-tissue architecture at the extraction site can be destroyed by _________.a. A careful techniqueb. Full-thickness flapsc. Use of anestheticd. All of the above

14. If insufficient bleeding is present, the socket walls should be _________.a. Widenedb. Perforated in several places with a small

round bur in a fast handpiecec. Perforated in several places with a small

round bur in a slow handpieced. Any of the above

15. When using a slow-speed handpiece, _________ will both remove debris and help to prevent osteonecrosis.a. Irrigationb. Anesthesiac. A big burd. Being quick

16. Bone-grafting materials and/or resorbable membranes are currently used for _______.a. Removal of cariesb. Ridge and site preservationc. Tooth restorationsd. None of the above

17. Materials used for bone grafting include _________.a. Autograftsb. Allograftsc. Xenograftsd. All of the above

18. Specific bone-grafting materials that have been used include _________.a. Deproteinized bovine boneb. Calcium sulfate hemihydratec. Chalkd. a and b

19. Bovine bone derivatives have been found to regenerate bone at _________.a. Extraction sitesb. Periodontal intra-bony defectsc. a and bd. None of the above

20. Soft-tissue margins are more aesthetically favorable when extraction sites are treated with _________.a. Both bone grafting material and a

resorbable membrane b. Only bone grafting materialc. Only a resorbable membraned. Full-thickness flaps

21. _________ developed a combination technique using deproteinized bovine bone and a resorbable membrane.a. Blackb. Didion Fillier c. Sclard. Mouyens

22. If an immediate implant is placed, bone-grafting material would _________.a. Fill the voids between the socket and

the implantb. Make implant placement impossiblec. Make the procedure take at least

five hoursd. None of the above

23. The Nu-Mem technique uses _________.a. Coral granules and a

resorbable membraneb. Deproteinized bovine bone and a

non-resorbable membranec. Deproteinized bovine bone and a

resorbable membraned. None of the above

24. Using the Nu-Mem technique, deproteinized bovine bone should fill the socket to _________.a. Half the depth of the socketb. The level of the crestal bonec. Three-quarters the depth of the socketd. All of the above

25. The purpose of the membrane using the Nu-Mem technique is to _________.a. Hold the grafting material in placeb. Prevent contamination of the sitec. a and bd. None of the above

26. After placement, the resorbable membrane can be secured in place using ________.a. Mattress suturesb. Criss-cross suturesc. Dental cementd. a and b

27. A provisional with _________ encourages soft-tissue contouring.a. An ovate pontic shapeb. A concave shapec. Extra acrylicd. None of the above

28. Around implants, _________ have been found to be effective in preserving the soft tissue.a. Custom healing abutmentsb. Ridge studsc. Full-thickness flapsd. None of the above

29. Resorbable collagen membranes are available as _________.a. Collagen plugsb. Collagen tapec. a and bd. None of the above

30. Support of the membrane during the initial healing period is obtained with _________.a. A long-lasting resorbable sutureb. A short-lasting non-resorbable suturec. A stainless steel stentd. None of the above

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Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

COURSE CREDITS/COSTAll participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 4 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 3274. The cost for courses ranges from $49.00 to $110.00.

Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANB’s annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANB’s Recertification Department at 1-800-FOR-DANB, ext. 445.

RECORD KEEPINGPennWell maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.

CANCELLATION/REFUND POLICYAny participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

© 2008 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

AGD Code 311

Educational Objectives1. Understand the importance of an atraumatic extraction technique, ridge and site preservation

2. Understand the pre-operative clinical assessment, and options to consider, for achieving atraumatic tooth extraction

3. Be knowledgeable about the various bone grafting materials available and the results that have been achieved using them

4. Know the steps involved in utilizing the Nu-Mem technique for ridge and site preservation.

Course EvaluationPlease evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No Objective #2: Yes No Objective #4: Yes No

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Do you feel that the references were adequate? Yes No

9. Would you participate in a similar program on a different topic? Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________

11. Was there any subject matter you found confusing? Please describe. ___________________________________________________ ___________________________________________________

12. What additional continuing dental education topics would you like to see? ___________________________________________________ ___________________________________________________

ANSWER SHEET

Extraction Site and Ridge PreservationName: Title: Specialty:

Address: E-mail:

City: State: ZIP:

Telephone: Home ( ) Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.