The document summarizes a study that evaluated buccal-lingual dimensional changes after tooth extraction and socket preservation using the "ice cream cone" flapless grafting technique. 11 sites in 11 patients were treated with this technique, which involves placing a bone allograft and collagen membrane shaped like an ice cream cone into the extraction socket. Measurements from CBCT scans, dental casts, and digital scans showed a mean buccal-lingual ridge width loss of 1.32 mm 6 months post-treatment. Despite this minor loss of width, the regenerated bone volume was sufficient for implant placement and osseointegration in all cases. The study concluded that the ice cream cone technique resulted in less contour changes

1. 1

2. Analysis of Buccolingual Dimensional
Changes of the Extraction Socket
Using the “Ice Cream Cone” Flapless
Grafting Technique
Journal of Clinical Periodontology
May 2014
Authors - Jocelyn H.P. Tan-Chu, DDS1, Frank J. Tuminelli,
DMD2, Kenneth S. Kurtz, DDS3, Dennis P. Tarnow, DDS4
PRESENTATION BY – DR. MD ABDUL HALEEM
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3. Introduction
Materials and methods
Results
Discussion
Conclusion
Reference
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4. INTRODUCTION
• Morphologic and dimensional changes of the alveolar ridge occur
after tooth extraction.
• Van Der Weijden et all demonstrated that the mean buccal-lingual
dimensional change of a human extraction socket was
approximately 4 mm if a preservation technique was not
performed.
• Other studies have shown that up to 50% of the horizontal bone
can be lost within 12 months post extraction.*

5. INTRODUCTION
• The greatest change in ridge contour occurs during the first
month after tooth extraction, which is both statistically and
clinically significant.
• The mean ridge width decrease after 6 months is 3 to 5 mm.*
• The resorption of the buccal plate may compromise esthetic outcomes in
treatment for implant-supported prostheses as the periodontium undergoes
atrophy after tooth extraction.*

6. INTRODUCTION
• Changes are not limited to hard and soft tissue contours, and can also include tissue
discoloration due to collapse with loss of the buccal bone plate.
• It is therefore important to maintain the natural contours of the residual ridge and
minimize the resorption of the buccal bone plate, especially in the esthetic zone with
implant supported prostheses.

7. INTRODUCTION
• There is a general consensus that socket preservation
techniques are beneficial in minimizing ridge shrinkage
following extraction.
• Osseous augmentation and preservation for creating and
maintaining bone volume for implants often involves the
use of bone graft materials with or without barrier
membranes.
• There are various techniques that have been suggested in several studies*; however, no
gold standard been established as to the ideal graft material nor whether a technique with
or without barrier membranes should be followed.

8. • Among the various techniques employed, the “ice cream cone
technique” has been advocated in type 2 extraction sockets due to
its simplicity.*
• Type 2 sockets are classified as the presence of soft tissue with the
buccal plate partially or completely missing before and after tooth
extraction.
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• However, no clinical data has been published to quantitatively assess the amount of
buccal-lingual dimensional change that occurs when using this “flapless grafting
technique”.
• The purpose of this retrospective study was to measure the buccal- lingual dimensional
changes using the ice cream cone “flapless grafting technique” in type 2 sockets as
described by Elian et al.*

9. METHOD AND MATERIALS
• This retrospective study was conducted in a hospital-based program (New York
Hospital Queens) by two residents and consisted of 11 sites treated with the ice
cream cone “Flapless grafting technique”.
• Patients were healthy nonsmokers and ranged in age from 24 to 78 years with a mean
age of 53.8 years.
• As standard protocol, treatment planning includes periapical radiographs, cone beam
computed tomographic (CBCT) scans and diagnostic casts of the sites were obtained
both pre- and post operatively.
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10. 10
BUCCOLINGUAL RIDGE DIMENSIONAL CHANGES

11. METHOD AND MATERIALS
• Irreversible hydrocolloid (Jeltrate, Dentsply) impressions were
made and immediately poured with type III dental stone to
fabricate casts.
• A digital caliper (Avenger MC0006) with an LED display
SAE/Metric sensitive to 0.01 mm was used to measure the casts
using a prefabricated acrylic template as a fixed reference point.
• A single operator using ×2.5 magnification optical loupes
recorded the measurements of the 11 extraction sites.
• The digital caliper was calibrated prior to each measurement. 11

12. • After tooth extraction the sockets were curetted thoroughly to
remove all soft tissue remnants before the placement of the
membrane and bone graft material.
• The facial buccal plate was evaluated with a periodontal
probe to measure the vertical extent of the buccal plate defect.
• Sites with soft tissue present but buccal plate partially (> 50%
or > 5 mm from free gingival margin) or totally missing after
postextraction were grafted with a bone allograft
(RegenerOss, Biomet 3i) and a resorbable collagen membrane
(OsseoGuard, Biomet 3i).
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13. • Any defect that was more than 5 mm missing from the free gingival margin of tissue was
categorized as a type 2 socket.
• The collagen membrane was cut into an ice cream cone shape and inserted internally into
the extraction socket and bone allograft was placed.
• Resorbable 4.0-chromic sutures (Ethicon) were used to suture and secure the membrane
over the site to prevent dislodgement or loss of the particulate bone graft material and
blood clot during initial healing.
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14. • All patients were placed on antibiotic therapy for 1 week
(amoxicillin 500 mg three times a day or clindamycin 150 mg
four times a day).
• Patients were also instructed to rinse twice per day for 7 days
with 0.12% chlorhexidine (Peridex) and were seen for follow-up
care 1 week postoperatively.
• CBCT scans were taken 6 months post healing for implant
therapy evaluation.
• This evaluation was performed to assess adequate radiographic
bone maturation and volume, as well as assist in selection of the
appropriate implant size.
• Measurements were recorded from the cross-sectional images of
pre- and post extraction CBCT scans.
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15. • The pretreatment ridge was measured at the widest buccal-lingual dimension from the
palatal bone at the alveolar crest to the facial aspect of the tooth.
• The posttreatment ridge was measured from the palatal bone at the alveolar crest to the
facial aspect of the regenerated sites that appeared to be the new buccal plate (where the
clearly delineated radiopaque hard tissues were observed).
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• CBCT measurements were taken from
the cross-section images of the healed
grafted sites using the midpoint of the
adjacent teeth as a reference point.

16. • Alginate impressions were made after 6 months healing with
irreversible hydrocolloid and immediately poured for cast
fabrication with type III dental stone.
• Measurements of the pre- and post extraction casts with
digital calipers were obtained by measuring the widest
bucco-lingual dimension possible using a prefabricated
acrylic template to standardize the measuring points.
• Pre- and post extraction casts were also scanned to verify the
recordings.
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17. RESULTS
• The epithelium surrounding the tooth extraction sites grew over the blood clot with
granulation tissue formation within 3 to 4 weeks and all sites healed uneventfully.
• All sites had adequate bone for implant placement after 6 months and did not require
further bone augmentation.
• The buccal-lingual dimensional change of the ridge from the pre- to post extraction
healed graft ranged from a loss of 0.46 mm to 2.25 mm with a mean of 1.28 mm
(CBCT scan), 0.31 mm to 2.71 mm with a mean of 1.36 mm (digital calipers), and
0.21 mm to 2.80 mm with a mean of 1.32 mm (digital scanner).
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18. MEAN BUCCAL-LINGUAL DIMENSIONAL CHANGE OF THE RIDGE

19. RESULTS
• All grafted sites were allowed to heal for 6 months before implant placement surgery.
• The regenerated bone volume appeared stable.
• Despite a mean buccal-lingual dimensional loss of 1.32 mm, all implants achieved
primary stability (minimum torque value of 35 Ncm) upon insertion.
• All 11 implants were immobile and osseointegrated after 6 months of implant
placement.
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20. RESULTS
• No marginal bone defects during second-stage exposure were noted.
• Periapical radiographs showed an absence of radiographic lucency with favorable
osseous healing.
• The implants were restored with metal ceramic screw-retained fixed dental
prostheses.
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21. DISCUSSION
• Augmentation of bone volume has been achieved using the GBR procedure.
• GBR is based on the principle that a barrier membrane is used for space maintenance
over a defect promoting the ingrowth of osteogenic cells and preventing migration of
undesired cells from the overlying soft tissues into the wound.*
• Protection of a blood clot in the defect and exclusion of gingival connective tissue
and provision of a secluded space into which osteogenic cells from the bone can
migrate are essential for a successful outcome.*
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22. • This study evaluated the buccal- lingual dimension of the ridge by following the ice
cream cone technique by Elian et al using a bioabsorbable membrane and allograft.
• The outcome from this study demonstrated that the tested preservation technique
resulted in less contour changes compared with nontreated extraction sites with type
1 sockets and “Flap elevation.
• Van der Weijden et al’s study and several others* showed that on average the
reduction in width of the alveolar ridge was 4.0 mm or more, to 50% after extraction.
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23. • These studies demonstrated rapid reductions in the first 6 months followed by
gradual reductions in dimensions thereafter.
• Moreover, these studies observed up to 12 months post extraction without any bone
preservation and the horizontal reduction was greater than vertical reduction in
human hard tissue.
• Thus, the ice cream cone technique offers repair with technical ease and less soft
tissue manipulation while allowing for secondary wound healing.
• It also minimizes mean width reduction to 1.32 mm.
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24. CONCLUSIONS
• This pilot study provides some information that the ice cream cone “Flapless
technique” is an easy approach that results in better horizontal regeneration of the
buccal bone plate.
• Even thou there is a mean ridge width loss of 1.32 mm in the buccal-lingual
dimensional changes compared between pre and post extraction phase, the
regenerated lost buccal plate was adequate to place an endosseous implant with
minor bone grafting.
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25. REFERENCES
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humans: A systematic review. J Clin Periodontol 2009; 36:1048–1058.
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26. REFERENCES
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27. REFERENCES
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28. Thank
You
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