Dry Sockets

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I have a topic for the group. It is on dry sockets.

Now that I graft nearly every extraction socket I notice that I get more dry sockets than I used to before the socket grafting craze.

My questions are as follows:

Do you notice that you are getting more dry sockets with socket grafting?
When you get a dry socket, how do you treat it?
What materials do you place?
When you lose the socket graft due to the dry socket do you ever go back and regraft the socket?

Mark

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I started doing all of my extractions as surgical extractions. I don’t always completely close the socket, but I do narrow it a bit. I haven’t had a dry socket in at least 12 years.

Jim

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Please explain/define “surgical extraction”

Tony

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It’s a very technical, scientific definition – I lay a flap. 😉

The truth is, it was a tip I received from an older dentist back when I was in school, and what was added was you can charge more for an extraction if you call it a “surgical extraction”. I have also found that if I am going to need to remove bone or section the tooth, having already reflected a flap just makes things easier.

If you’re having more dry sockets with your bone grafts than without, there is probably a reason for it. You may want to check what your assistants are up to as they set up the room. Your staff may be inadvertently be setting you up for post op infections that could lead to dry sockets. I had a run of post op infections a few years ago and found that to be the case with me.

Jim

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I guess from the lack of responses that I am the only one experiencing dry sockets. I mix DFDBA and CaSo4 at about an 80:20 ratio, don’t pack the sockets too tightly and suture collagen over the top tucked just under the flaps. I have tried to follow the protocol of my good friend Bob Horowitz and try not to booger it up too much and even try to make sure my assistants wash their hands once or twice a day and occasionally sterilize the instruments.

I would be interested in hearing if anyone else experiences dry sockets please.

Thanks

Mark

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Mark,

I perform a fair amount of socket grafting (mostly Lifenet FDBA, Puros Allograft) and fortunately have never seen osteitis in a grafted socket.

Mauricio

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MAURICIO
Are you covering the socket orifice and if so, with what?

Tony

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this is chris chondrogiannis,

We’ve had a couple of post op infections under pontics when the restorative DDS placed too much pressure on the graft with the pontic decreasing vascularization. It does create significant discomfort to the patient and compromises the graft. if there is no pressure on the graft you shouldn’t get any infections. I use biooss with a collagen membrane. no problems other than what was described above.

Chris

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Mark knows that I too have had some osteitis problems with the FDDBA/CaSO4 combo. We’ve discussed it. I find that, if I place half set plaster in the orifice, it often disappears and the graft is probably washes away. I think this occurs irrespective of the amount of bleeding, or lack thereof within the socket.
I’ve tried covering the plaster with a disk of membrane material (e.g. Ctyoplast), sewing it into place, and that works well. I also find that a free gingival (disk) graft placed in the orifice works really well – very rapid closure of the wound with minimal indentation. However, there’s the additional morbidity with the latter technique.

Jeff,

I found your offering interesting. I’m interested to know if the facio-lingual dimension of the sites that you augment (after 8 weeks of healing) have substantially greater F-L dimensions than sockets/ridges that are “preserved” via immediate socket grafting.

I find that some sockets/ridges maintain there dimension well with the preservation grafting and others don’t, despite the grafting. Of course, we’ve all seen this either/or phenomenon with ungrafted/preserved, naturally healed sockets (i.e. some collapse and some don’t). Maybe it has to do with the thickness of the facial and lingual walls of bone of the sockets.

Tony

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Tony,

I find that at 4-8 weeks, if an area is flapped, it really doesn’t matter what I put in the socket since the first thing that happens is the contents of the socket are curetted right out. That is why I don’t bother putting anything expensive in the socket because it ends up down the suction anyway. The amount of buccal resorption is certainly variable and probably depends on initial buccal plate thickness, biotype, trauma from extraction, etc. And to my knowledge, most data suggests that putting stuff into a socket without additionally placing a membrane and obtaining primary closure, does not change the amount of buccal resorption or vertical alveolar height.

Jeff

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Jeff,

Boyne, the great socket healing researcher of the 60s, 70’s 80’s showed that maximum osteoblasia occurs in a socket at week eight. It seems to me that you wouldn’t want to remove that stuff.

Tony

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Tony,

To quote some other old friends, Evian and Rosenberg, you are correct as long as you are talking about the contents of the center of the socket. My problems are not in the center of the socket though, they are at the coronal aspect of the buccal plate. The centers always heal. It’s the buccal-occlusal line angle that is the issue.

Jeff

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Many good points have been made, especially the importance of blood supply. As I’ve said many times, THE NATURE OF THE BLOOD CLOT WILL DETERMINE THE HEALING, and as Mort Amsterdam has said many times, IT IS THE DRY CASES THAT SCARE ME.

Chuck

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Tony,

Could it be that the CaSO4 is obliterating intra-socket spaces that normally would allow for influx of blood and higher proportion of clot/graft? Additionally, maybe the hardened mix separates at some time from the bone, and at that point no new blood invades the socket, and you get osteitis. Thirdly, maybe in the process of stabilizing the material in the socket, the sutures exert excessive pressure and hence osteitis,

I have used Calcium Sulfate in the past (during my residency, 95-98), and had some separations from the grafted area, followed by invagination of soft tissue. Granted, these were more compromised areas, without the benefit of surrounding walls for stability. I only wish other materials had the ease of use of CaSO4, since I never used it again.

Just an idea…

Julio

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Wow Chuckee…I never knew you were paying attention!

Ernesto

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Julio,

Well may be as you suggest. Maybe that’s why the proportion of CaSO4 to FDDB is so small as recommended by the plaster advocates. Admittedly, my dosing hasn’t been performed with atomic accuracy.

What about Silberg? Mark, how precisely do you apportion the two components as recommended by Bob Horowitz?

Tony

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To all,
I had my first dry socket in 10-12 yrs when I started using PRGF to graft a couple years ago. Could never get a straight answer as to the reasons why. Any similar experiences?

Ernesto

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Tony,

Before I get to your question, a bit of philosophical non-sense….I’ve flip-flopped on the subject of socket preservation over the short course of my career. There were times when I agreed with my partner Jeff and proselytized that there was rarely a need for socket preservation. I also went through some unscientific ‘data-gathering’ periods where I grafted everything. Like most of us, I’ve experimented with a number of materials determined by availability around the office, cost, and attractiveness/persistence of the bone-rep-du-mois. In cases where I did not think grafting was crucial to the success of the case, but where the results might provide a valuable learning experience, I merely passed on the costs of the materials to the patient. I photographed and radiographed extensively at 2,4,8, and 12 weeks, hoping that my documentation could someday form the basis of a bone grafting textbook that would catapult me to fame and fortune…

Don’t be looking for my name in the Quintessence catalog anytime soon. What I found in my limited data-gathering wasn’t all that exciting and led me back to my UT roots – in my hands particulate FDBA gave me the most predictable results. Sorry – no cores, histo, or carbon-14 dating to back up my data. Just a decent personal track history of dense, bleeding bone at three months most of the time. I also settled on middle ground on the graft vs. no graft debate…I have no way of looking up the numbers but would say I graft about 60-70% of the extraction sites that do not receive immediate implants. This may sound high to some, but I would say in general we (I am assuming most of us in the group are specialists…if not they are a very vocal minority) see a higher percentage of complex cases that might benefit from grafting (max anterior, proximity to sinus,etc…).

Now, to answer your question – yes, I do cover it. Like Doug Heller I had concerns over costs and resorption of exposed membrane until I stumbled into the ACE collagen membrane. It is relatively economical (about $40 dollars for a 15-20mm piece), and has nice stiffness to it, which I like over a socket. It also, in my experience, appears quite resilient to early breakdown when not quickly epithelialized. I elevate about 3 mm of tissue bucally and lingually and tuck it in, then stabilize it with vicryl sutures. It find it routinely promotes rapid and predictable epithelialization of the socket, minimizing the time the graft/membrane complex is exposed to the oral schmootz Steve Brown referred to (also of great concern to me initially)

Eager to try the vicryl mesh…can anyone tell me where I can purchase it

Mauricio

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WOW-
All this starting with a dry socket.
I’m going to insert a couple of article abstracts and address some comments related to case report type studies I’ve done and what we’re seeing.

Authors Full NameOkamoto, T. Okamoto, R. Alves Rezende, M C. Gabrielli, M F.
InstitutionDisciplina de Cirurgia e Traumtologia Buco-Maxilo-Facial, UNESP, Aracatuba, Brasil.
TitleInterference of the blood clot on granulation tissue formation after tooth extraction. Histomorphological study in rats.
SourceBrazilian Dental Journal. 5(2):85-92, 1994.
AbstractThe interference of a blood clot in the first postoperative hours of dental extraction wounds was studied in rats. Sixty male albino rats were divided into two groups: Group I, immediately after extraction of right maxillary incisor the gingival mucosa was approximated and sutured; Group II, after 6 to 8 minutes postoperatively the blood clot was removed with saline irrigation and absorbent paper cones. The mucosa was then approximated and sutured. Six animals in each group were sacrificed after 12 hours, 1, 4, 7 and 10 days. There was a profound delay in healing in Group II since, although a new blood clot was later formed, it was not organized. The quality and the constitution, maintenance and retraction of the clot are the regulating factors in connective tissue formation during alveolar healing.

Because of this study, I take my photo immediately after the tooth is extracted, degranulate quickly and let the socket fill with blood, whether I’m grafting or just placing a barrier over the socket.

AbstractSuccessive changes in the vascular pattern during the osseous healing of extraction wounds were investigated by studying microvascular casts under a scanning electron microscope. The casts were prepared utilizing the plastic injection method, after the extraction of the upper four incisors of the Japanese monkey (Macaca fuscata). Five days after extraction, vascular buds have sprouted from a pre-existing blood vessel on the alveolar wall into the blood clot, and leakage of the plastic injected was found from the tips of these buds. One week after extraction, newly-formed vessels have extended widely to the socket center, and dilated vessels have arborized towards the socket opening. Two weeks after extraction, the socket was filled with thick, newly-formed vessels. In the socket fundus, the woven bone was formed between irregular vascular networks, but was arranged different in the socket wall. Four weeks after extraction, the new bone forming on the socket wall became thickened and converted to a lamella-like bone. Inside it the woven bone was raised from the fundus, and blood vessels leaving it were decreased in their thickness and passed toward the socket center. Five weeks after extraction, the new bone structures came up to the level of the socket opening, the surface of which appeared as a shallow concavity (pivot), from which vascular bundles were directed to the socket opening. A beginning of the bone-remodeling was seen in osseous trabeculae in the socket fundus. Six weeks after extraction, almost all of the socket became filled with new trabeculae, between which, fine vascular networks were sorted out and communicated with the periosteal vascular network beyond the socket margin. The interalveolar septum between the extraction sockets was thickened by deposition of the lamella-like bone to be remodeled to a cancellous bone. It can be said that microvascular patterns formed through all stages of the osseous healing of the extraction wounds contributed to a woven bone formation and its development.

I know that rats heal at a different rate than humans, but I’ve never subscribed to removing osteoid from a healing socket. I know that Cy Evian showed in humans that there’s bone in them thar sockets at 30 days. I just don’t like to get rid of it.
In general, I place a dense teflon barrier over a socket whether or not I’m grafting. There have been a number of case report studies by Barry Bartee (developer of TefGen and cytoplast) and myself. I’ve used the technique even with total absence of buccal and/or significant loss of palatal bone as long as the barrier can be kept in a stable location to protect the blood clot for 3 weeks. Crump et al showed better/quicker bone healing in rabbit skull defects under dense teflon than either GoreTex or removable barriers.
I haven’t seen a dry socket since Barry showed me his technique when I visited him in Texas (nope, not a lot of Periodontists there/then) back in 1995. I agree with those who have raised concerns about leaving resorbable barriers exposed. Histologically, even when we cover them, I’m seeing more connective tissue encapsulated graft materials coronally than under d-PTFE.
The other main advantage of d-PTFE is that the surgical procedure is minimally invasive, no traditional flaps are elevated and the membrane is tucked under the periosteum ONLY to cover past the edge of the defect.
I agree with Jeff G – anything that bleeds in my office other than root planing is surgery. Flapless is what we strive for and the Piezosurgery unit helps with that. I will say, though, since I’ve used it, I have seen a low, but noticeable number of small sequestrae after extraction, anywhere from 6 to 12 weeks postop.
The only time I’ve seen graft failure is when patients don’t take antibiotics postop.
Tony- I’ve been trying to get Dr. Vercellotti to fund 4 different research projects and running against a brick wall. I’ll keep going. I know their histo on early wound healing after ultrasonic osteotomy preparation is impressive. I think it will be different with extractions, however, as it is much harder to keep the tips cool.
So, for now, my decision tree for extraction socket preservation/augmentation is:
1. ALWAYS do something.
2. If there’s enough proximal bone and a bit of facial or lingual to maintain a teflon barrier at the shape I want, blood clot alone. Approximate reentry time – 3 months.
3. If I need space maintenance under the barrier, either DFDBA/CalMatrix or DFDBA-TCP (pure, no HA) in a 50-50 mix with Cal Matrix for larger sockets. Reentry – 3-4 months without TCP, 4-6 months with TCP.
4. When I osteotome at the time of extraction, DFDBA-TCP/CalMatrix and I wait 6 months.
I almost always cover with d-PTFE. Although I use lots of Bone Gen, CapSet and CalForma, they are hard to use and I don’t think they stay intact as long in my hands as they do in David Anson’s or John Sottosanti’s. I’m concerned about cracking, wicking and loss of barrier function. I will often protect a calcium sulfate barrier with teflon.
Too many trains of thought to keep track of. Hope I’ve been able to help a bit with some of my experience.
Calcium sulfate powder (not preset pellets which resorb and are replaced by bone at 3 months) is eliminated from the socket by 6 weeks, timed with angiogenesis (shown by Strocchi) and the beginning of new bone formation. I am more concerned with non- or extremely slowly resorbing graft materials in the socket as in the study below. One quick note on graft materials. Artzi and Weinrib did a study in prepared defects in dogs. Artzi Z. Weinreb M. Givol N. Rohrer MD. Nemcovsky CE. Prasad HS. Tal H. Biomaterial resorption rate and healing site morphology of inorganic bovine bone and beta-tricalcium phosphate in the canine: a 24-month longitudinal histologic study and morphometric analysis. [Comparative Study. Journal Article. Research Support, Non-U.S. Gov’t] International Journal of Oral & Maxillofacial Implants. 19(3):357-68, 2004 May-Jun. They showed the quickest healing under barrier protected blood clot alone defects. In this model, healing was delayed in the central portion of the “socket” at 3 months with BioOss.
AND, on a separate note, Dr. Lindhe calls the coronal millimeter or so of crestal alveolar bone, what Jeff and the rest of us are so concerned about losing in the aesthetic sites, bundle bone. He feels it goes away after extraction, never to return.
Time to give someone else a chance.

I guess this was like asking Jeff Ganeles his thoughts on immediate loading/immediate socket implants.

Bob

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I do a lot of extraction/socket grafts and I have yet to experience a dry socket. I do everything I can to avoid laying a flap. As I recall from my training days, Dr Ramfjord taught us that some bone loss would occur every time a flap is made, so I do everything I can to avoid it. I like the instruments called “proximators.” They are very thin, sharp, strong chisels that can be inserted between the tooth and the bone interproximally. I degranulate the socket extensively after the extraction, using a very sharp spoon-like curette. Ten minutes before placing the graft I mix 1/2 cc Puros cancellous allograft with 1-2cc of the patients blood-drawn from the anticubital fossa(I can’t afford PRP.) This “clotted graft” is then placed in the socket with minimal condensation. Early on I used to take a “plug” of palatal tissue a suture it in, and I found the healing to be fantastic. Now I use a thin slice of a Collaplug and reconstitute it in blood too, before suturing it in. This is much faster and doesn’t create a second wound. I find the healing acceptable and have never experienced a dry socket.

Mike

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My proportioning has been done with Stevie Wonder accuracy. I will have to work on measuring and trying to insure more of an 80:20 ratio. I will continue to use the CaSo4 because I love the bone that I see when I implant 9 to 10 weeks later. It is generally dense and hard ( wish I still was) and the healing is faster then when I use DFDBA alone.

Mark

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Mark,

I agree with all two of the three points that you make:

I too will be more precise in measuring the quantities (by weight) of the two ingredients; have to get out my old dope scale
I also think that the density of the bone, and the rapidity of its development is much faster with the FDDBA/plaster combo
I’m glad that I’m not so fast to get hard any more. It’s easier on my ticker and my self-esteem knowing that I can’t do anything about it if it worked better.

Leave it to Silberg and me to screw up a perfectly professional endeavor such as this listserve.

Tony

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Jeff,

I see that the studies have now been done on Bio-Oss in extraction sockets-.I’m not sure if they are published but look forward to seeing Lindhe’s presentation and results at the Quintessence Symposium in Sydney . See attachment.

David

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David,

Good to hear from you. I think when selecting (or not selecting) graft materials we should decide if we want regeneration or repair. In the “old days” regeneration was allways my primary objective. Now I feel repair may be as good or better especially in the esthetic zone.
Following extraction, If enough natural bone remains to stabilize an Implant,I prefer to place the Implant (at that time) skewed toward the lingual (or palatal) and concentrate my efforts toward protection (not regeneration) of the precious bone. I use FDDBA for gap fill and follow up with connective tissue grafting in conjunction with a provisional. I believe the FDDBA serves as a matrix for clot formation, retards the resorption of bone, and facilitates the repair of the wound. In addition, the placement of FDDBA dosen’t seem to interfere with connective tissue grafting at the time of Implant placement or further down the road. It seems an immediate provisional (with or with-out immediate loading) also facilitates soft tissue repair (at least short term). I sometimes repeat connective tissue grafting years later for esthetics and /or to protect the bone.
I have applied similar principals to socket preservation,and found the benefits to be insignificant. I feel repair or regeneration (if you really think it’s possible) is best accomplished at the time of Implant placement along with some form of restoration.

Chuck

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Mark-
When not using CalMatrix or CapSet, I only approximate the ratio. Having used pure calcium sulfate in numerous forms, I don’t think there’s such a thing as too much.
AND, I thought we were keeping the site clean!
Bob Horowitz
PS – In response to Mike Krause’s statement by Dr. Ramfjord, Moghaddas and Stahl (I believe 1974) showed that there’s approximately 1mm of bone loss each time a flap is elevated. That’s where Dr. Lindhe got his loss of bundle bone from.

Bob

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Can we think of a name for Viagra with Calcium Sulfate? Would the FDA approve it? Think of it this way – it gets more bone, better bone, quicker bone, harder bone AND increases vascular supply. Enough said?
Do we want to really bring the blog that low?

Bob

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David

Haim Tal’s group has a number of human extraction socket studies with histomorphology.

Bob

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Bob,

I’m assuming Lindhe will present more controlled animal studies and showing specific alveolar dimensional changes compared to controls as he has done for immediate implants. I’ll let you know.

David

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Bob

If you use Cialis it will stay around longer as well.

Doug

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David

Thanks for the update. We were hoping to do some of those studies in our department with Giuseppe Cardaropoli, BUT it didn’t work out as planned.

Bob

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That’s why we have this site – to get advice from our “friends”.

Alan-
We need to have a barbecue this summer. Maybe we can have our former Governor arrange “entertainment”.

Bob

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