2.6. Clinical Procedure
trauma, bleeding, mesiofacial, tooth
BLEEDING, DECAY, STERILE, BLIND, PLAQUE
All the eligible patients received a professional oral hygiene session two weeks before the initial surgical intervention. Chlorhexidine, 0.2% mouth rinses (Periokin, Spain), was prescribed twice daily for two weeks. To assess their periodontal status, plaque index, probing depths, gingival recession, and bleeding on probing (BOP) were evaluated at six sites (midfacial, mesiofacial, distofacial, midpalatal, mesiopalatal, and distopalatal) around the tooth to be extracted as well as on the adjacent teeth.The diagnostic stone cast was made after an intraoral impression with a silicone impression material (Zhermack Zeta Plus, Italy). The surgical stent was fabricated using a vacuum former and Biostar acrylic sheet 1.0 mm thick (JINTAL, China). Two points (2 and 5 mm from the gingival margin) were made at the implant placement site and marked on the stent by drilling holes with a diameter of 1.0 mm. for buccal/lingual alveolar ridge measurement. Furthermore, these points were filled with gutta-percha for use during the preoperative tomography to provide radiopaque landmarks indicating the locations for comparative tomographic ridge width measurement. All scans were achieved by Kavo OP 3D PRO (Biberach, Germany) using fixed parameter voxel size, 66 kV and 9.9 mA. Scans were exported in DICOM format to 3D viewer software (Blue Sky Plan 4.7.2, Blue Sky Bio, USA), as shown in The facial gingival thickness was assessed using an endodontic reamer (no. 40) fitted with a rubber stopper and inserted perpendicularly at 2 and 5 mm through the guidance holes in the stent under the influence of the topical anesthetic gel. When resistance felt, the rubber stopper was repositioned in contact with the gingiva and fixated in place with a flowable composite. The resultant distance was measured with a digital caliper with 0.01 mm sensitivity.All dental surgeries were carried out under the administration of local anesthesia. The technique of flapless tooth extraction was performed using periotomes and forceps to minimize surgical trauma. All alveolar sockets were gently curetted, irrigated with normal saline, and inspected for bony wall defects. According to the developers' instructions, the extracted retained roots were prepared immediately after extraction with the KometaBio device (KometaBio, Smart Dentin Grinder, USA). First, a high-speed handpiece removes all decay, artificial material, gutta-percha, and debris from the patient's extracted roots so that only the clean tooth root remains. The KometaBio tooth grinder was used to crush the roots containing dentin.The resulting root dentin particulate material underwent a 3-step first: dentin cleanser solution was poured into the dish with the particulate for 5 minutes at room temperature. After that, a sterile gauze was used to dehydrate the solution. Next, the phosphate-buffered saline (PBS) was poured into the dish, covering the particulate completely. A sterile instrument was used to mix the particulate and dehydrate it using a new sterile gauze. Repeat this step with the PBS solution again. This step is essential to neutralize the pH levels. Finally, the ADB with particle size 300-1200 microns is ready for immediate grafting. The extraction sockets in the study group were filled with ADB powder and then covered with gel foam (Roeko Gelatamp, Germany). Finally, figure eight suture was used to stabilize the extraction sites in both groups (Four months after extraction, standardized CBCT scans (with the same old stent inside the patient's mouth) were taken to evaluate alveolar bone changes at the sites of interest. The second surgical intervention was performed under local anesthesia with an incision and reflection of the full-thickness mucoperiosteal flap. Core biopsies were harvested for histological analysis at implant osteotomy sites using 2.6 mm inner/3.6 mm outer diameter trephine burs in 10 mm depth in the planned implant axis under copious irrigation of normal saline (Komet Dental, Lemgo, Germany) followed by implant placement from Bionnovation Implants Biomaterial (Brazil) and suturing.Core biopsy samples were fixed in formalin, embedded in paraffin wax, and sectioned for histological examination. Afterward, hematoxylin and eosin (H&E) staining was carried out, and blind quantitative histological analysis was performed by a trained specialist using the ImageJ® v1.52a software (U.S. National Institutes of Health, Bethesda, Maryland, USA). ImageJ® scan downloaded from 