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\begin{document}

\title{Application of pre-medicated collagen sponges with regenerative
biomaterials for management of an infected extraction socket}



\author[1]{Mohammed E. Sayed}%
\affil[1]{Jazan University Faculty of Dentistry}%


\vspace{-1em}



  
  \date{June 15, 2024}


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\selectlanguage{english}
\begin{abstract}
Localized infection of the extraction socket can compromise bone quality
and quantity within the socket and bone support for the adjacent
dentition, precluding immediate rehabilitative interventions. The use of
local scaffolds containing effective antimicrobial agents may help to
control infection for successful regeneration and implant placement.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Exodontia is associated with complications such as postoperative
infection, accounting for 1.4\% of treated cases.\textsuperscript{1} A
large-scale prospective study reported very low incidence of
postoperative infection in teeth with preoperative history of
infection.\textsuperscript{2} As an alternative to tooth replacement,
implant-supported restorations may comprise a viable treatment modality
for rehabilitation of partially edentulous patients and have shown
higher success rates for single-tooth
replacement.\textsuperscript{3}Chen and Buser\textsuperscript{4}
published a classification system for the implant-placement timing
following tooth extraction and categorized the placement as immediate,
early with soft-tissue healing, early with partial bone healing, or
delayed. Although immediate dental-implant placement in fresh extraction
sockets is an established treatment modality,\textsuperscript{5-7} a
recent meta-analysis\textsuperscript{8}reported that immediate implant
placement is associated with a higher risk of early implant loss. The
success rate could significantly decrease by the presence of risk
factors leading to early implant failure at second-stage surgery, and
infection was the most significant risk factor with the highest odds
ratio compared to other factors.\textsuperscript{9} Immediate implants
can offer predictable results in sites with history of periapical and
periodontal infections, as careful debridement is performed before
implant insertion.\textsuperscript{10} Moreover, infection of the
adjacent teeth may complicate the success of immediate implants in
short- and long-term follow-up assessments.\textsuperscript{11} Thus,
socket infection may compromise the anatomical structures necessary for
primary implant stability and the success of immediate implants. The
inter-radicular bone in molar sites, for instance, is a crucial
parameter playing a role in dental implant stability and
success.\textsuperscript{12} Therefore, in such cases, guided bone
regeneration may be the first step to prepare the implant bed for later
surgical placement.\textsuperscript{13}

In addition to mechanical debridement of the infected socket,
pharmacological interventions may be helpful for management of local
aseptic conditions. The potential benefits of systemic antibiotic
treatment following guided tissue and bone regeneration have been
questioned.\textsuperscript{14-17} The application of postoperative
systemic antibiotics may be helpful in reducing discomfort following the
guided tissue-regeneration procedure.\textsuperscript{18} Local
application of chlorhexidine chips\textsuperscript{19} and metronidazole
gel\textsuperscript{20} showed promising results in guided tissue
regeneration of periodontal defects. Nonetheless, applying these agents
for guided bone regeneration of compromised extraction sockets as a
preparatory step for future implant therapy requires evaluation. This
report aims to introduce the strategic application of pre-medicated
collagen sponges containing both chlorhexidine and metronidazole
together with a particulate bone graft and collagen membrane for guided
tissue and bone regeneration following extraction of a split mandibular
first molar with purulent infection, fistula opening, and severe
vertical bony defect of the adjacent second premolar.

\textbf{Case Description and Results}

A 36-year-old Saudi Arabian woman presented to a private clinic with a
chief complaint of tooth mobility and pain. The patient was medically
fit with dental history of a few composite restorations performed 2
years previously. No medication usage was reported. Intraoral clinical
examination revealed that the intraoral soft and hard tissues were
within the normal limits. Tooth \#19 presented with a vertical fracture
extending deep below the gingival margin with noticeable mobility of the
broken proximal halves. A fistula opening with purulent discharge on
pressure palpation was detected on the buccal gingival tissue. A
vitality test using the cold-testing technique was performed on tooth
\#20 and revealed a vital pulpal response. Radiographic examination
revealed that tooth \#19 had a deep fracture line extending halfway
between the cementoenamel junction and mesial root apex. A large
peri-apical/periodontal infection was observed around the fracture area
and distal root surface of tooth \#20 (Fig. 1). Probing of the mesial
aspect of the fractured tooth showed an 11-mm-deep pocket with excessive
bleeding on probing.

A treatment plan was formulated to include extraction of tooth \#19 with
simultaneous guided bone regeneration followed by implant-supported
crown replacement, also addressing the infected post-extraction socket
and distal root surface of tooth \#20. Local anesthesia was administered
by buccal and lingual infiltration of Septanest with adrenaline
1/100,000 (Septanest, Septodont, France) and a short needle. A sulcular
incision was made using blade 15c mounted on a \#5A blade handle
(Hu-Friedy, Chicago, IL, USA) extending from the mesial aspect of tooth
\#20 to the distal aspect of tooth \#18 for surgical accessibility. A
pouched mucoperiosteal flap was reflected using a Buser Periosteal
Elevator (Hu-Friedy, Chicago, IL, USA), and tooth \#19 was extracted
using atraumatic extraction forceps (Hu-Friedy, Chicago, IL, USA) (Fig.
2). The extraction socket was thoroughly debrided to remove all
granulation tissues. The distal root surface of tooth \#20 was curetted
carefully using a Molt surgical curette (Hu-Friedy, Chicago, IL, USA).
Grade II mobility was noted in tooth \#20 due to significant loss of
bone support from the distal root aspect. After extraction, the debrided
socket showed a two-walled defect with buccal-plate loss, denuded distal
root surface of tooth \#20, and damaged inter-radicular bone.

Guided bone regeneration was planned for future implant placement. Three
pieces of resorbable pre-medicated collagen sponge containing lidocaine,
chlorhexidine, and metronidazole (Alvanes, Vladmiva, Belgorod, Russia)
were adapted to the distal root surface of tooth \#20 to facilitate
hemostasis and antimicrobial control of the infected area for proper
tissue/bone regeneration of the defect side. A resorbable collagen
membrane (T-Barrier Membrane, B\&B Dental Implant Co., Italy) was tacked
under a buccal flap to ensure stability upon socket management. An
equal-parts mixture of small-sized particulate allograft and xenograft
bone materials (ACE Surgical Supply, Brockton, MA) was used to fill the
rest of the socket. The collagen membrane was then wrapped around to
cover the socket and tacked under the minimally reflected lingual flap.
A wound dressing collagen tape (HeliTape; Miltex Integra, Princeton, NJ)
was used to cover the collagen membrane and tacked under the buccal- and
lingual-flap edges. The site was sutured with mesial and distal simple
interrupted knots, and a figure-of-eight technique was used to stabilize
the socket contents using 5-0 monofilament polypropylene sutures (SMI
sutures, St. Vith, Belgium). The socket seal technique was implemented
by application of cyanoacrylate coating (PeriAcryl 90 HV; GluStitch
Inc., BC, Canada) on the surgical field (Figs. 3a and 3b). Occlusal
adjustment of tooth \#20 was performed to achieve light contact on
maximum intercuspation and excursion movements. Postoperative
instructions and a prescription of Augmentin 625 mg TID for 7 days,
ibuprofen 400 mg prn pain, and Parodontax daily mouthwash for 2 weeks
were provided. The patient was recalled 2 weeks later for suture removal
and at 1, 4, and 6 months postoperatively for site evaluation. Clinical
and radiographic evaluations of the site were performed at the 6-month
recall visit to plan for implant surgery (Figs. 4a and 4b).

Following administration of local anesthesia, a flapless and free-hand
approach was used to place a 4.2\selectlanguage{ngerman}×9 implant along with the cover screw in
a slightly sub-crestal vertical position (Astra Tech Implant EV;
Dentsply Sirona, Mannheim, Germany) (Fig. 5). An implant insertion
torque of 45 N·cm was achieved. The punched-out tissues were adapted and
sutured to seal the punched holes (Fig. 6). Postoperative instructions
and medication were provided, and the patient was followed up per
standard protocol. Three months after implant placement, the implant was
uncovered following the tissue punch, and a healing abutment of 4-mm
height was attached accordingly. Surgical closure and postoperative
instructions were provided. An implant-level closed-tray impression
technique was performed along with shade-matching 3 weeks after the
implant-uncovering procedure. A screw-retained implant-supported
zirconia crown was designed, inserted, and torqued to 25 N·cm to the
internal implant connection (Fig. 7). The screw hole was closed with
Teflon tape and a flowable composite. Occlusal adjustment was
accomplished with light contact on centric and eccentric movements. The
patient was followed up every 3 months in the first year and every 6
months thereafter. The periodontal condition of tooth \#20 improved, and
no mobility was noted on recall visits. Post-treatment clinical
photographs showed favorable soft-tissue health and level on the buccal
and lingual aspects of the implant crown (Figs. 8a and 8b). CBCT
radiographs were obtained 1 and 2 years post-treatment and revealed
optimum bone quantity and quality around the implant and on the distal
root surface of tooth \#20 (Figs. 9 and 10).

The report was conducted in accordance with the Helsinki Declaration of
1975, as revised in 2013. The patient provided written informed consent
for the publication of this case report and accompanying figures.
Patient anonymity was ensured. The report was exempt from institutional
review board approval.

\textbf{Discussion}

This report presented a clinical approach for application of local
pharmaceutical agents together with standard biomaterials for guided
tissue and bone regeneration. Although natural teeth may be extracted
for many reasons, Osaghae and Azodo\textsuperscript{21} reported that
tooth splitting was the etiological factor for 5\% of the extracted
posterior teeth, of which 10\% were mandibular first molars. The
prognosis of split teeth with a fracture line extending deep in the
sub-gingival area is usually poor\textsuperscript{22}; therefore, the
teeth in question require replacement with implant or tooth-supported
prosthesis.

A meta-analysis\textsuperscript{23} reported no difference in success
rates between immediate implant placement in infected and non-infected
extraction sockets. However, such treatment options are contraindicated
in cases with purulent socket infection and poor bone configuration
following extraction.\textsuperscript{24} Accordingly, a more careful
approach involving proper implant site preparation prior to placement is
feasible to render favorable implant positioning and angulation as
described here.

Management of post-extraction sockets is variable. Introduction of
hemostatic collagen sponges caused delays in the healing process of the
extraction sockets and suppressed differentiation of bone-forming
cells.\textsuperscript{25} As a variant of the bone graft form used
here, sticky bone resulted in better soft- and hard-tissue healing and
regeneration when used for socket grafting following third-molar
extraction in a split-mouth clinical study.\textsuperscript{26} Several
biological agents have been reported to supplement the standard
biomaterials in expediting healing and improving postoperative results
following guided tissue and bone-regeneration
procedures.\textsuperscript{27} Compared with a collagen-sponge group,
supplemental use of recombinant human bone morphogenetic protein 2 with
bone graft material resulted in superior bone gain on the distal
surfaces of second mandibular molars following third molar
extraction.\textsuperscript{28} A recently published systematic review
and meta-analysis supported the use of platelet-rich fibrin following
extraction and reported a faster wound-healing rate and lesser
postoperative complications.\textsuperscript{29} The application of
readily available agents such as pre-medicated collagen sponges may
present a convenient strategic option to supplement readily successful
biomaterials for regenerative therapies.

A randomized double-blinded clinical trial\textsuperscript{30} found
that repeated application of chlorhexidine-containing chips is
beneficial to control sites with active periodontal disease. Local
application of controlled-release chlorhexidine chips improved the
quantity of bone gain upon tissue-regenerative procedures, and infection
control may be crucial for the success of such treatment
interventions.\textsuperscript{19} Additionally, evaluation of
metronidazole-gel application for tissue regeneration showed that local
application of metronidazole gel yielded successful clinical outcomes in
treating vertical bony-defect cases along with other biomaterials used
for guided tissue regeneration.\textsuperscript{20} However, no study
has outlined the effects of combined application of these agents in
tissue and bone-regeneration procedures. This report utilized a
pre-medicated collagen sponge containing both active agents in a
scaffold form, facilitating convenient manipulation and adaptation
during the surgical procedure and ensuring local release of these agents
during the healing process of tissue and bone regeneration.

\textbf{Conclusion}

Within their limitations, this report suggests that the application of
pre-medicated collagen sponges containing chlorhexidine and
metronidazole can help control local infection and facilitate
significant tissue and bone regeneration in a compromised socket
presenting with active and purulent infection, loss of buccal bone
plate, and marked vertical bone defects of the adjacent tooth.

\textbf{References}

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\textbf{Figure Legends}

\textbf{Figure 1} . Pre-treatment radiograph indicating split tooth \#19
and significant infection around its mesial root and distal root surface
of tooth \#20.

\textbf{Figure 2} . Extracted tooth \#19 showing extension of the
fracture line and the size of the radicular granuloma.

\textbf{Figure 3} . A composite image illustrating (a) surgical closure
using the socket seal technique after extraction of tooth \#19 and (b)
socket fill following extraction with radiolucent gap on the distal root
surface of tooth \#20, which represents pre-medicated collagen sponges.

\textbf{Figure 4} . A composite figure illustrating (a) clinical view of
site \#19 6 months following extraction and GBR procedures and (b)
radiographic evaluation of site \#19 showing progressive healing and
bone fill.

\textbf{Figure 5} . Postoperative view of the implant following
placement in a two-stage surgical approach.

\textbf{Figure 6} . Postoperative clinical view of the implant site
following closure of the surgical hole using the excised native soft
tissue.

\textbf{Figure 7} . Postoperative clinical view of the screw-retained
implant crown following insertion.

\textbf{Figure 8} . A composite figure illustrating clinical views of
the implant-supported crown from the (a) buccal and (b) lingual aspects
2 years after treatment completion.

\textbf{Figure 9} . CBCT radiograph obtained the year following
completion of treatment, indicating progressive bone gain around the
implant and the distal root surface of tooth \#20.

\textbf{Figure 10} . CBCT radiograph obtained 2 years following
completion of treatment indicating adequate bone fill and maturation
around the implant and distal root surface of tooth \#20.

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