Techniques for Extraction Socket Regeneration for Alveolar Ridge Preservation

Background: The socket preservation technique involves filling the bone defect created after tooth extraction with a bone substitute material. This helps to reduce bone resorption of the post-extraction alveolar ridge. Various types of bone substitute biomaterials are used as augmentation materials, including autogeneic, allogeneic, and xenogeneic materials. The purpose of this study was to evaluate changes in alveolar ridge dimensions and alterations of optical bone density in sockets grafted with two different biomaterials. Additionally, bone biopsies taken from the grafted sites underwent histological evaluation. Methods: This study enrolled 10 generally healthy patients, who were divided into two equal groups. Patients in the first group were treated with an allogeneic material (BIOBank®, Biobank, Paris, France), while patients in the second group were treated with an xenogeneic material (Geistlich Bio-Oss®, Geistlich Pharma AG, Wolhusen, Switzerland). Tooth extraction was performed, following which the appropriate material was placed into the debrided socket. The material was secured with a collagen membrane (Geistlich Bio-Gide®, Geistlich Pharma AG, Wolhusen, Switzerland) and sutures, which were removed 7 to 10 days after the procedure. Micro-CBCT examinations were performed, for the evaluation of alveolar ridge dimensions and bone optical density, at 7–10 days and six months after the procedure. Bone trepanbiopsy was performed simultaneously to the implant placement, six months after socket preservation. The retrieved biopsy was subjected to histological examination via hematoxylin and eosin (H&E) staining and Masson’s trichrome staining. Results: The results showed that the allogeneic material was more effective in preserving alveolar buccal height and was probably more rapidly transformed into the patient’s own bone. Sockets grafted with the xenogeneic material presented higher optical bone density after six months. Both materials presented similar effectiveness in alveolar width preservation. Conclusions: Based on the outcomes of this study, it can be concluded that both materials are suitable for the socket preservation technique. However, the dimensional changes in the alveolar ridge and the quality of the newly formed bone may vary depending on the type of biomaterial used.

Background: Post-extraction alveolar ridge resorption can hinder proper denture fabrication and dental implant placement, which requires a specific minimum bone dimension. Socket preservation techniques, including bone grafts and barrier membranes, aim to mitigate this bone loss. However, the individual roles of bone grafts and barrier membranes in preserving ridge dimensions remain unclear. This study aimed to evaluate whether socket preservation using a collagen membrane alone is as effective as the conventional technique involving both a bone graft and a membrane in preserving alveolar ridge height and width following tooth extraction. Materials and Methods: Eighteen extraction sites were randomly assigned to three groups: • G+M Group: Socket preserved with demineralized freeze-dried bone allograft (DFDBA) and collagen membrane. • M Group: Socket preserved with collagen membrane alone. • N Group: Socket allowed to heal naturally. • Ridge width was measured using dental casts at baseline and 6 months post-extraction. Ridge height was assessed via intraoral periapical radiographs at baseline, 1 month, and 6 months post-extraction. Statistical analyses included ANOVA for inter-group comparisons and paired t-tests for intra-group comparisons over time. Results: Both ridge height and width decreased in all groups over time. However, no significant difference was observed in ridge height among the groups. A statistically significant difference was found in ridge width, with the G+M group showing less resorption compared to the M and N groups. Conclusion: Using a collagen membrane alone may adequately preserve vertical bone height. However, combining a bone graft with a membrane appears superior in preserving alveolar ridge width

Tooth extraction procedures often lead to bone resorption, which can have adverse effects on the dimensions of the alveolar ridge. Research has shown that socket preservation techniques using bone graft substitutes can effectively minimize early bone loss in such cases. α-calcium sulfate hemihydrate (α-CSH) has garnered significant attention as a potential bone graft material due to its favorable properties, including osteoconductivity, angiogenic potential, and biocompatibility. Considering these facts, we developed a preliminary protocol for applying α-CSH in addressing alveolar bone loss following tooth extraction. This research's general objective is to evaluate the feasibility and initial effectiveness of α-CSH as bone-inducing graft material for socket preservation after tooth extraction. This preliminary clinical trial will involve 30 fresh extraction sockets from individuals aged 18-35 years. The participants will be divided into 2 groups: one group will receive α-CSH graft material after tooth extraction for socket preservation, while the other group will not receive any graft material. Throughout the study, the participants will be closely monitored for safety measures, which will include clinical examinations, radiographic imaging, and blood tests. Radiographic imaging will be used extensively to assist the progress of bone formation. The study commenced enrollment in August 2022 and is scheduled to conclude post assessments and analyses by the end of 2023. The results of the study are anticipated to be accessible in late 2024. This clinical study represents the initial investigation in humans to assess the feasibility and efficacy of α-CSH in alveolar bone regeneration. We hypothesize that the inclusion of α-CSH can greatly expedite the process of bone formation within fresh sockets, resulting in a swift restoration of bone height without the disadvantages associated with harvesting autogenous bone graft. Indonesia Registry Center INA-D02FAHP; https://tinyurl.com/2jnf6n3s. DERR1-10.2196/49922.

Bone retention, bone augmentation, and bone regeneration are central topics in oral surgery, implantology, and periodontology. Bones and teeth are the only structure within the body where calcium and phosphate participate as functional pillars. Despite their mineral nature, both organs are vital and dynamic. The major sequel from human tooth loss is the loss of alveolar bone. After tooth extraction, the residual alveolar ridge generally provides limited bone volume because of ongoing, progresive bone resorption. The process of healing on bone defect in the region of alveolar ridge passes throught several stages from the coagulum formation to the mature lameral bone. The healing process within postextraction sites reduces the dimension of the socket over time. Bone grafts and bone graft substitutes support regeneration in bone defects and can be used for bone augmentation. Bone graft substitutes are clasiffied by their origin as autogenous bone grafts, bone graft substitutes (allogenic from human origin and xenogenic materials from animal origin), and synthetic (alloplastic) bone graft substitues, manufactured from mineral raw materials, whose composition is precisely defined and whose availability is is unlimited. Alveolar ridge augmentations are classified according to their morphology and severity. Bone augmentation techniques can be used for the application of socket defect grafting, horizontal ridge augmentation, vertical ridge augmentation, and sinus augmentation. Ridge augmentation methods are therefore very important developments and have so far been promising especially in view of the fact that life is incresingly prolonged especially in economically well-developed countries and the incidence of the disease is expected to further increase in the future. Keywords Tooth extraction, Socket Augmentation, Alveolar ridge Bone regeneration, Grafting Bone grafting techniques, Bone graft substutes, Ridge preservation, Autogenous, Alloplastic, Horizontal ridge augumentation, Vertical ridge augumentation, Guided bone regeneration, Guided tissue regeneration.

Bone Biology, Harvesting, Grafting for Dental Implants: Rationale and Clinical Applications Arun K. Garg

size and shape of the residual alveolar ridge (4,5). Dental bone grafts (BGs) play an important In addition, the loss of alveolar bone, because role in situations in which structural or functional of periodontal disease or secondary to surgery, is support, or both, is necessary. BGs are used to a source of numerous complications, including provide a scaffold for bone regeneration: promotloss of the periodontal attachment, impaired restoing union of osteotomies and fractures; augmentration of the periodontium, and poor patient aesing bony defects caused by trauma or surgery; thetics (4,5). Thus, a primary goal of treatment is restoring bone loss caused by dental disease; fillrepair and regeneration of the entire periodontal ing extraction sites to preserve the height and attachment complex which consists of cementum, width of the alveolar ridge (ridge preservation); periodontal ligament (PDL), and alveolar bone and augmenting and reconstructing the alveolar (6). ridge (1,2). In addition to alveolar ridge preservaClinically, different substitute BGs have been tion and augmentation and repair of bony defects, utilized for ridge preservation postextraction; grafting is being performed to improve the outridge augmentation; in periodontal bony defects; come of implant dentistry through sinus lift proceand in conjunction with the placement of dental dures of the maxillary sinus and to fill bony voids implants (7–9). The literature is replete with suc(e.g., in the immediate postextraction implant) and cessful applications of BGs, both with or without the osteotomy created during traditional implant membrane barriers. There is increasing evidence surgery (3). that most synthetic BG substitutes do not require Successful rehabilitation of a dental arch, with the utilization of a membrane (10). fixed prosthetic replacement of lost teeth, depends

Background: Tooth extraction is followed by a resorption of the bone in the buccal or facial portion, up to 50% in the first six months after the extraction. Bone loss mainly results from damage to the periodontal bone ligament complex. Socket preservation is a surgical procedure aimed to maintain an alveolar ridge after extraction, eliminating or minimizing the need for future augmentation in implant-prosthetic rehabilitation. Socket preservation techniques use some regenerative material such as bone graft and membrane. Objective: To discuss socket preservation procedures using bovine bone graft and pericardium membrane. Method: A 48-year-old woman presented to the Dental and Oral Hospital of Hasanuddin University to have tooth 47, which was mobile and extruded, extracted. Patient had no systemic disease and did not use any drugs. Clinical and radiograph examinations showed bone resorption in the surrounding edentulous area. The patient wanted to wear prosthesis but the bone resorption showed that socket preservation was needed to maintain the alveolar ridge high. The case was diagnosed as chronic periodontitis. Atraumatic extraction was done and bovine bone graft was placed in the socket, followed by the placement of pericardium membrane. Soft tissue healing was clinically evaluated. Results: Control period after one week showed apparent uneventful clinical healing in the socket. Patient was satisfied with the treatment. Conclusion: The socket preservation procedure is an effective treatment for maintaining the alveolar ridge high from excessive resorption, especially for prosthesis treatment. Keywords: alveolar ridge, bone bovine, pericardium membrane, socket preservation

The repair and treatment of lost or damaged alveolar bone is of great significance in dentistry. Gene-activated matrix (GAM) technology provides a new way for bone regeneration. It is a local gene delivery system, which can not only recruit cells, but also influence their fate. For this purpose, we fabricated a bone morphogenetic protein 2 (BMP-2) gene-loaded absorbable gelatin sponge (AGS) and studied its effect on promoting alveolar bone formation and preventing resorption following tooth extraction in rats. In order to obtain better transfection efficiency, polyethylenimine-alginate (PEI-al) nanocomposites were synthesized and used as gene vectors to deliver BMP-2 cDNA plasmids (PEI-al/pBMP-2). The transfection efficiency, BMP-2 protein expression and osteogenic differentiation of the cells were investigated in vitro. In vivo, we established an alveolar bone regeneration model by extracting the rats' left mandibular incisors. The rats were randomly assigned into 3 groups: control group, unfilled sockets; AGS group, sockets filled with PEI-al solution-loaded gelatin sponges; AGS/BMP group, sockets filled with PEI-al/pBMP-2 solution-loaded gelatin sponge. Radiological and histological assays were performed at 4 and 8 weeks later. In vitro transfection assays indicated that PEI-al/pBMP-2 complexes could effectively transfect MC3T3-E1 cells, promoting the secretion of BMP-2 protein for at least 14 days, as well as increasing the expression of osteogenesis-related gene, ALP activity and calcium deposition. In vivo, western blot analysis showed BMP-2 protein was expressed in bone tissues of AGS/BMP group. The relative height of the residual alveolar ridge and bone mineral density (BMD) of the AGS/BMP group were significantly greater than those in the AGS and control groups at 4 and 8 weeks, respectively. Histological examination showed that, at 4 weeks, osteoblasts had grown in a cubic shape around the new bone in the AGS/BMP group, suggesting new bone formation. In conclusion, the combination of PEI-al/pBMP-2 complexes and gelatin sponge could promote alveolar bone regeneration, which may provide an easy and valuable method for alveolar ridge preservation and augmentation.

Maxillary Tuberosity Block Bone Graft: Innovative Technique and Case Report

Background:Tooth extraction will provoke changes in alveolar bone morphology and dimensions. Postextraction bone resorption can lead to significant problems for restorative dentistry. Therefore, the extracted tooth socket needs to be preserved to reduce alveolar ridge bone resorption. This research aimed to analyze the expression and levels of osteocalcin, collagen 1, and osteoblasts in extracted tooth sockets filled with a combination of mangosteen peel extract and demineralized freeze-dried bovine bone xenograft (DFDBBX).Material and Methods:Fifty-six Cavia cobaya, whose lower left incisors had been extracted, were divided into eight groups according to the substance used to fill their sockets on days 7 and 30, Poly ethylene glycol, DFDBBX, mangosteen peel extract, or a combination of mangosteen peel extract and DFDBBX. This research was conducted in several stages; the application of mangosteen peel extract combined with graft material was performed as the form of tooth extraction socket preservation. The C. cobaya rats were subsequently examined by immunohistochemical methods to measure osteocalcin and collagen 1 expressions, whereas histological examination was conducted to calculate the number of osteoblasts in accordance with the duration of the research.Results:On days 7 and 30, the group treated with a combination of DFDBBX and mangosteen peel extract which had the highest expression and levels of osteocalcin, collagen 1, and osteoblasts.Conclusion:The administration of mangosteen peel extract combined with DFDBBX as a means of tooth extraction socket preservation can increase osteocalcin and collagen 1 expression. Consequently, osteoblasts as a means of alveolar bone regeneration will increase in number.

The use of hydroxyapatite bone substitute grafting for alveolar ridge preservation, sinus augmentation, and periodontal bone defect: A systematic review

Following the loss of a tooth, the new edentulous area of the ridge will undergo several adaptive modifications due to changes in function within and surrounding the socket. This bone resorption explains the need for socket preservation techniques in areas of esthetic concerns and functional demands. Demineralized freeze-dried bone allograft (DFDBA) possesses greater osteoinductive potential due to the exposure of bone morphogenetic protein (BMP-3​​​​​​)​and collagen fibrils and can be used efficiently in socket preservation techniques. DFDBA yields better results when combined with an autologous platelet concentrate, such as platelet-rich fibrin. Therefore, we formulated this randomized controlled clinical trial to assess the clinical and radiovisiographical outcomes of platelet-rich fibrin (PRF) and DFDBAs for extraction socket preservation in humans at different time intervals. This was a randomized controlled trial with 100 people as study subjects, and they wererandomly divided into two groups: the test group (DFDBA and PRF placed in the extraction socket) and the control group (natural healing of the extraction socket). Clinical and radiographic evaluation using radiovisiography (RVG) was done at baseline, three-month, and six-month intervals. Cone-beam computed tomography (CBCT) was used at six months to determine the bone density in the test and control groups. When compared from baseline to six months, the percentage change in clinical and RVG measurements for the test group was 15.96% (11.9064 mm) and 16.77% (12.1840 mm), respectively, whereas for the control group, it was 46.09% (14.0396 mm) and 47.61% (14.5716 mm), thus indicating lesser bone resorption in the test group as opposed to the control group. CBCT values also showed greater bone density for the test group (682.3120 HU) than the control group (503.8336 HU). This study demonstrates the advantages of DFDBA bone graft with PRF compared to natural healing in achieving socket preservation by maintaining the marginal and buccolingual bone levels.

The aim of this report is to describe a significantly deficient case of alveolar bone that was managed by alveolar bone augmentation using a technique of distraction osteogensis and onlay bone grafting prior to dental implant placement. Injury to the teeth and alveolar ridge of the maxillary anterior region can cause a severe alveolar ridge deficiency resulting in ridge atrophy and maxillary retrognathism. The loss of these teeth and alveolar bone together with fibrotic scar formation can result in adverse changes of the interarch space, occlusal plane, arch relationship, and arch form which complicates rehabilitation and can compromise the esthetic outcome. While implant dentistry has become a new paradigm in oral reconstruction and replacement of missing teeth, ideal implant positioning can be compromised by inadequate alveolar bone in terms of bone height, width, and quality of the bone itself. Correction of osseous deficiencies with ridge augmentation allows ideal implant placement and creates a more natural soft tissue profile which influences crown anatomy and esthetics. A 20-year-old female presented with a complaint of poor esthetics resulting from oral injuries incurred in a traffic accident six years previously. In addition to a mandibular parasymphyseal fracture, five maxillary anterior teeth and the most of the alveolar ridge were lost. Clinical examination revealed severe loss of bone in the maxillary anterior region, an absence of a labial sulcus, loss of upper lip support, and a slight over eruption of the mandibular anterior teeth. In preparation for dental implants a distraction osteogenesis surgical procedure was done to lengthen the height of the alveolar ridge. After a three-month healing period, the width of the residual ridge was found to be insufficient for implant placement. To correct this deficiency, a bone graft of a cortiocancellous block was harvested from the chin and fixed to the labial aspect of the ridge. To facilitate revascularization, small perforations were made in the cortical bone of the alveolar ridge at the recipient site before cancellous bone retrieved from the donor site was gently placed between the bone block and the ridge. The patient was then appropriately medicated and healing was uneventful. After three months, the width of the residual ridge was assessed to be adequate for endosseous implants. The clinical result reported here has shown several procedures may be necessary for the rehabilitation of a trauma patient. Distraction osteogenesis per se may not always satisfactorily improve the anatomical alveolar anatomy but it has advantages over other methods of augmentation. It can improve the height and also expand the soft tissue for further bone grafting. Augmentation of the alveolar bone with an onlay bone graft often provides the desired gain of bone, allows for the ideal placement of dental implants, and improves any discrepancy between the upper and lower arches.

Leucocyte- and platelet-rich fibrin (L-PRF) has been tested for enhancing alveolar ridge preservation (ARP), but little is known about the local release profile of growth factors (GF), and the clinical equipoise related to its efficacy remains. This study compared the patterns of GF release, early soft tissue healing, and alveolar ridge resorption following unassisted healing and L-PRF application in non-molar extraction sockets. Atraumatic tooth extraction of two hopeless teeth per patient was followed by unassisted healing or L-PRF placement to fill the socket in 18 systemically healthy, non-smoking subjects. This intra-individual trial was powered to assess changes in horizontal alveolar ridge dimensions 1 mm below the crest of alveolar bone. GF concentrations in wound fluid were assessed with a multiplex assay at 6, 24, 72, and 168 h. Early healing was evaluated with the wound healing index and changes in soft tissue volumes on serial digital scans. Hard tissue changes were measured on superimposed CBCT images after 5months of healing. L-PRF resulted in higher GF concentrations in wound fluid (WF) than in the control, but no differences in release patterns or time of peak were observed. No inter-group differences in early healing parameters were observed. Alveolar bone resorption was observed in both groups. No significant inter-group differences were observed in hard tissue healing 1, 3, or 5 mm apical to the original bone crest or in the ability to digitally plan a prosthetically guided implant with or without bone augmentation. L-PRF increased the GF concentrations in WF of extraction sockets without shifting the pattern observed in unassisted healing, while the increased delivery did not translate into clinical benefits in early wound healing or ARP. The current findings question the assumption that increased local concentrations of GF by L-PRF translate into improved clinical outcomes. Additional definitive studies are needed to establish the benefits of L-PRF in ARP (ClinicalTrials.gov NCT03985033).

This prospective clinical analysis reports on the use of coral granules in alveolar ridge preservation procedures in a population of young, growing patients. The sample consisted of 21 patients, 12 females and 9 males, with a mean age of 13.6 years. These 21 patients had 48 dento-alveolar defects suitable for augmentation with coral granules, and were followed clinically and radiographically for 3-7 years after augmentation. There were two areas of augmentation: 17 defects in the anterior maxilla resulted from traumatic tooth loss, and 31 defects in the posterior maxilla and mandible resulted from the extraction of ankylosed retained primary molars with no permanent succedaneous teeth. Between 1-2 ml of coral granules were implanted into the alveolar bone defects left by the extraction of teeth in both the areas. This was in order to preserve the remaining edentulous ridge from further alveolar ridge resorption. The goal of the procedure was to preserve the alveolus so that in the future, a dental implant could be placed to replace the missing tooth, after jaw growth had stopped, without the need for a bone graft. The coral granules appeared to be totally replaced by the host bone on follow-up clinical and radiographic examinations. The two areas of the jaws behaved quite differently. In the anterior maxilla, where tooth loss was secondary to trauma, the coral granules restored the alveolar ridges temporarily. However, over the years of follow-up in this study, the coral granules failed to provide sufficient bone to support the placement of a dental implant without using a bone graft in 14 of the 17 defects or 82.4% of sites. In the posterior maxilla and mandible, where tooth loss was due to the elective removal of ankylosed primary molars, 29 of the 31 defects or 93.5% of sites were successful as they were able to support the placement of an osseo-integrated dental implant without the use of a bone graft. The alveolar sparing technique was more successful in maintaining an alveolar ridge sufficient for the placement of a dental implant without bone grafting in the posterior maxilla and mandible, where tooth loss was secondary to the elective removal of ankylosed deciduous molars than in the anterior maxilla, where tooth loss was secondary to trauma. Coral granules seem to be more suitable in the posterior maxilla and mandible where there were ankylosed deciduous teeth and congenitally absent permanent teeth than in the traumatized anterior maxilla. In successful sites, coral granules can spare the alveolus from residual ridge atrophy or resorption, obviating the need for a bone graft. This reduces patient morbidity, as a second surgical donor site is avoided because bone graft harvesting is made unnecessary.