Flapless Extraction Research Articles

Flapless extraction of impacted mandibular third molars: A contemporary surgical approach

The aim of this review is to evaluate the clinical outcomes of flapless extraction of impacted mandibular third molars compared to traditional flap-based techniques, with a focus on patient satisfaction, complication rates, and overall surgical efficiency. The extraction of impacted mandibular third molars (wisdom teeth) is a common procedure in oral and maxillofacial surgery, traditionally performed using a flap-based technique. While this method provides clear access to the impacted tooth, it is often associated with significant postoperative morbidity, such as pain, swelling, and extended recovery time. Recent innovations have introduced flapless extraction as a minimally invasive alternative, aiming to minimize tissue trauma and preserve periosteal integrity. This technique, however, presents its own set of challenges, including limited visibility and technical demands.This review analyzes the current literature on flapless extraction techniques, drawing from retrospective studies, randomized controlled trials, and clinical case reports. The data include comparisons of postoperative outcomes between flapless and traditional methods, emphasizing factors such as operative time, postoperative discomfort, and the frequency of complications. Findings indicate that flapless extraction generally results in reduced postoperative pain, swelling, and faster recovery times compared to traditional flap-based techniques. Patients who undergo flapless extraction report higher satisfaction due to less postoperative discomfort and a quicker return to normal function. However, the technique poses challenges in cases of deeply impacted teeth, where the lack of a flap may hinder complete access and increase the risk of complications. Flapless extraction represents a promising evolution in the surgical removal of impacted mandibular third molars, offering several advantages over traditional methods, particularly in reducing postoperative morbidity. However, the technique requires precise surgical skill and is not suitable for all cases. Careful case selection is crucial, and continued research is needed to further validate its efficacy and safety in complex scenarios.

Feasibility study of a novel digital template-guided flapless extraction for maxillary palatal impacted teeth.

With the increasing maturity of 3D printing technology, the application of digital guide template in the extraction of impacted teeth has become more sophisticated. However, for maxillary palatal deeply impacted teeth, there still exist significant clinical challenges. This experiment introduces a novel digital guide template and innovatively employs a flapless technique to explore a minimally invasive approach for the extraction of palatal deeply impacted teeth. This experiment included 40 patients diagnosed with palatal completely impacted teeth, randomly divided into an experimental group and a control group. The experimental group used the new digital guide template for flapless extraction, while the control group employed the traditional freehand flap technique. The experimental group can significantly reduce the localization time of palatally impacted teeth (P < 0.001), with total surgery times of 18.15 ± 4.88min and 22.00 ± 7.71min for the experimental and control groups, respectively (P = 0.067). Although there were no significant statistical differences between the two groups in terms of intraoperative bleeding, adjacent tooth damage, infection, or damage to nearby important anatomical structures, the experimental group showed significant improvements in postoperative pain (P < 0.05), swelling (P < 0.001), and patient satisfaction (P < 0.001) compared to the control group. Compared to traditional freehand flap surgery, flapless extraction of palatally impacted teeth guided by digital templates significantly reduces the localization time of impacted teeth and demonstrates notable advantages in some postoperative complications. Future studies with larger sample sizes are needed to substantiate the feasibility of this technique.

A Socket Seal Technique With the Use of Autologous Dental Roots for Socket Seal: A Case Series.

The literature identified variations in socket seal surgery, each with limitations. This case series aimed to observe the outcome of using autologous dental root (ADR) for socket sealing on socket preservation (SP). A total of 9 patients with 15 extraction sockets were documented. After flapless extraction, the xenograft or alloplastic grafts were placed in the sockets. Autologous dental roots were prepared extraorally and applied to seal the socket entrance. All SP sites healed uneventfully. Cone-beam computed tomography (CBCT) scan was performed after 4-6 months of healing to evaluate ridge dimensions. The preserved alveolar ridge profiles were verified on CBCT scans and during implant surgery. Implants were placed successfully with a reduced need for guided bone regeneration. Histological biopsy specimens were examined in 3 cases. The histological examination demonstrated vital bone formation and osseointegration of graft particles. All patients completed the final restorations and were monitored for 15.56 ± 9.08 months after functional loading. The favorable clinical outcomes support the use of ADR for SP procedures. It was not only accepted to patients but also easy to perform with low complication rates. The ADR technique is thus a feasible method for socket seal surgery.

An Alternative Technique for Ridge Reconstruction of Extraction Socket with Buccal Dehiscence: A Clinical Case Report

A clinical case report describing the use of an alternative ridge reconstruction technique to augment an extraction socket with buccal dehiscence. Unassisted healing following flapless extraction of teeth possessing such buccal wall defects leads to severe bone and soft tissue deformities, and an aesthetic compromise. Current treatment strategies are based on the assumption that maintenance of the buccal tissues leads to superior clinical outcomes. Our proposed ridge reconstruction technique challenges this concept by suggesting that a lack of buccal bone in fact, enhances bone augmentation with our proposed treatment strategy, as demonstrated by the positive radiographic changes. Our technique consists of socket grafting with deproteinised bovine bone particulates and socket sealing with an immediate ovate pontic. The ability to achieve effective circumferential socket seal is paramount in maximising ridge augmentation. The increase in bone volume thus provides the ideal surgical environment for implant placement in the prosthetically driven position, ensuring optimal aesthetics and function of the implant. The patients also benefit from the provision of an immediate tooth replacement and the reduced postoperative morbidity as this is a flapless technique, involving no sutures or barrier membranes. The ultimate result is the ability to achieve superior clinical outcomes with maximum benefit for the patients

Central Toxic Keratopathy after Small Incision Lenticule Extraction.

Small incision lenticule extraction (SMILE) is a corneal refractive surgical procedure based on flapless extraction of the intrastromal lenticule created by a femtosecond laser. Central toxic keratopathy is a rare, non-inflammatory complication of flap laser surgery using the femtosecond laser. This disorder is typically characterized by the triad of noninflammatory central corneal opacification, striae, and loss of stromal bed tissue, and it results in a hyperopic shift that causes a reduction in vision quality and it is not among the complications we are familiar with after the SMILE. Because of the growing number of refractive surgical procedures worldwide there may be an increasing incidence of this disorder. A differentiation from an inflammatory or infectious etiology and appropriate treatment is necessary for recovery. In this case report, we report a case of central toxic keratopathy in a 25 years old male patient after SMILE laser surgery.

P-68027613-297 - Role of nano-porous-hydroxyapatite derived from eggshell in socket preservation and implant supported restoration

Background Ridge preservation using various bone graft substitutes have been performed but none of the studies have recommended the material of choice for grafting. So, the study was aimed to analyze the outcomes of nano-porous-hydroxyapatite (nHA) graft material for socket preservation and implant restoration in the grafted sites using clinical and radiographic& microCT parameters. Methods A total of 20 sockets were preserved using nHA in a flapless extraction technique. The sites were divided randomly into two groups for implant placement at two different time intervals (4th & 6th-month). During implant placement, the trephine biopsy was obtained using a 3x10mm trephine bur. The bone regeneration was assessed using CBCT and microCT, correlated with histomorphometry. Patients were observed for 3 years with 6 month intervals for implant survival. The study was approved by the institutional ethics committee. Results All patients showed a well-preserved ridge and fourteen implants were placed successfully. Histomorphometric and Micro-CT analysis revealed a newly formed bone with interconnecting trabeculae of woven bone. Plenty of cellular osteoid in the form of trabeculae with intervening loose relatively dense cellular fibrous tissue was observed. Radiographic analysis showed increased density with a trabecular pattern in 74% and a ground glass pattern in 24% of the sockets within three months. Conclusion nHA grafting showed successful bone regeneration with less connective tissue components and osseointegration with a successful implant-supported prosthesis at the end of three years of follow-up. nHA restores and improves physical functions and enhances survival and quality of life. So, nHA may emerge as a novel graft substitute. Ridge preservation using various bone graft substitutes have been performed but none of the studies have recommended the material of choice for grafting. So, the study was aimed to analyze the outcomes of nano-porous-hydroxyapatite (nHA) graft material for socket preservation and implant restoration in the grafted sites using clinical and radiographic& microCT parameters. A total of 20 sockets were preserved using nHA in a flapless extraction technique. The sites were divided randomly into two groups for implant placement at two different time intervals (4th & 6th-month). During implant placement, the trephine biopsy was obtained using a 3x10mm trephine bur. The bone regeneration was assessed using CBCT and microCT, correlated with histomorphometry. Patients were observed for 3 years with 6 month intervals for implant survival. The study was approved by the institutional ethics committee. All patients showed a well-preserved ridge and fourteen implants were placed successfully. Histomorphometric and Micro-CT analysis revealed a newly formed bone with interconnecting trabeculae of woven bone. Plenty of cellular osteoid in the form of trabeculae with intervening loose relatively dense cellular fibrous tissue was observed. Radiographic analysis showed increased density with a trabecular pattern in 74% and a ground glass pattern in 24% of the sockets within three months. nHA grafting showed successful bone regeneration with less connective tissue components and osseointegration with a successful implant-supported prosthesis at the end of three years of follow-up. nHA restores and improves physical functions and enhances survival and quality of life. So, nHA may emerge as a novel graft substitute.

Assessment of immediate clotting after flapless extraction using piezosurgery or turbine handpiece in patients receiving dual antiplatelet therapy.

This study aimed to investigate the efficacy of piezosurgery (PI) in promoting immediate clotting after flapless extraction in patients undergoing dual antiplatelet therapy (DAPT). In this randomized controlled trial, 80 DAPT patients were equally divided into the PI and turbine handpiece (TH) groups. Accordingly, flapless extraction of a single tooth using PI or TH was performed on each patient, and the immediate clotting status was evaluated. The results of the preoperative hematological examinations, surgery-related variables and postoperative complications were recorded for analysis. Both groups presented with low platelet aggregation and similar coagulation functions. The PI group exhibited a higher proportion of patients with normal intra-alveolar clotting (≤30 min) (70% vs. 40%, P = 0.007) and fewer intraoperative complications (25% vs. 47.5%, P = 0.036) than that in the TH group. Logistic regression analysis indicated that the applied instrument was an independent risk factor for prolonged immediate bleeding (odds ratio = 3.10, 95% confidence interval: 1.20-8.00, P = 0.019). Intergroup differences were insignificant in terms of the other surgery-related variables and postoperative complications, except for the longer surgical duration in the PI group. The application of PI may contribute to better immediate clotting in DAPT patients after flapless extraction compared with the use of TH.

Evaluation of Horizontal and Vertical Buccal Ridge Dimensional Changes After Immediate Implant Placement and Immediate Temporization With and Without Bone Augmentation Procedures: Short-Term, 1-Year Results. A Randomized Controlled Clinical Trial.

This prospective randomized controlled clinical trial aimed to compare changes in the horizontal and vertical soft tissue and the alveolar ridge dimension over the course of 12 months following immediate implant placement and temporization with or without simultaneous augmentation with a deproteinized bovine bone mineral with 10% collagen (DBBM-C). Thirty-two patients with a hopeless maxillary anterior tooth and fully intact sockets received an immediate implant and provisional or custom healing abutment after a flapless extraction. Patients were randomized to a control group (n = 16), which received no graft, or to a test group (n = 16), which received DBBM-C grafts. Horizontal and vertical soft tissue changes as well as soft tissue thickness were compared digitally between groups on casts obtained from impressions made at baseline and 3, 6, and 12 months. The test group showed less horizontal dimensional change than the control group; however, the change between the two groups was not statistically significant. Vertical dimensional soft tissue changes from baseline to 12 months showed a statistically significant difference at the distal papilla, favoring the test group. No statistically significant difference was observed for vertical changes between both groups at mesial papillae and midbuccal soft tissue; however, the test group showed lower values overall. No statistically significant differences in soft tissue thickness between groups were detected. Immediate implant placement and temporization with and without adding DBBM-C demonstrate favorable clinical outcomes regarding horizontal and vertical soft tissue changes. Both groups showed loss of tissue volume. Adding DBBM-C in the gap of immediately placed implants slightly lowered the change in tissue parameters, which was not statistically significant, for the first 12 months after implant placement.

Comparison of Peri-implant Soft Tissue Color with the Use of Pink-Neck vs Gray Implants and Abutments Based on Soft Tissue Thickness: A 6-Month Follow-up Study.

To compare the optical effects of an immediately placed anodized pink-neck implant and abutment vs a conventional gray implant and abutment in relation to soft tissue thickness 6 months after the restoration was completed. Forty patients with a hopeless maxillary anterior tooth received an immediate implant and an immediate provisional or custom healing abutment after flapless extraction. Participants were randomized to receive either a conventional titanium implant (control) or a pink-neck implant (test). All patients then received two identical CAD/CAM titanium abutments (one conventional gray, delivered first, and one anodized to appear pink, delivered 3 weeks after) and a zirconia crown. A spectrophotometer was used to record the color of the peri-implant mucosa and gingiva 3 weeks after delivery of each abutment and 6 months after the final restoration was delivered. The color difference between the two sites was calculated (ΔL*, Δa*, Δb*), and correlations with soft tissue thickness, change in ridge dimension, and implant position were assessed. Irrespective of the randomization group, changing the abutments from gray to pink showed a change in color between the peri-implant mucosa and the natural gingiva. Patients with a thin gingival biotype showed a statistically significant color change (P = .00089) in the a* axis, meaning that the gingiva appeared more pink (Δa*). No significant correlation between the soft tissue color and buccolingual collapse, vertical recession, or implant position was observed in either group. The difference in color observed between the peri-implant mucosa and the gingiva was considerable in all groups. Anodized pink implants and abutments could reduce the difference in the red aspect (Δa*) of the peri-implant mucosa compared to the adjacent gingiva in patients with a thin biotype.

Accuracy of Bone Sounding in Assessing Facial Osseous-Gingival Tissue Relationship in Maxillary Anterior Teeth.

The aim of this study was to evaluate the accuracy of bone sounding (BS) in assessing the facial osseous-gingival tissue relationship (FOGTR) of failing maxillary anterior teeth. Dental records of patients who received immediate implant placement (IIP) at the maxillary anterior area were screened. Mid-FOGTR prior to extraction (BS), and immediately after flapless extraction (direct bone level [DBL] measurement) were analyzed. A total of 160 patients with 190 maxillary anterior teeth were included. The mean FOGTR obtained from BS and DBL were 3.19 ± 0.71 mm and 3.47 ± 1.29 mm, respectively (P = .004). The two measurements were identical 83.2% of the time, within 1-mm discrepancy 4.7% of the time, and > ± 1 mm discrepancy 12.1% of the time. When discrepancy was observed, BS underestimated DBL 14.2% of the time and overestimated 2.6% of the time. Though statistically significant, the correlation was weak (Pearson correlation coefficient r = .238, P = .0018). BS is an acceptably accurate and minimally invasive diagnostic tool for measuring FOGTR. However, while the mean difference between BS and DBL measurement is small (0.28 mm), the large range of difference can be alarming. Therefore, clinicians should always prepare alternative treatment options for IIP prior to extraction.

Clinical relevance of dimensional bone and soft tissue alterations post‐extraction in esthetic sites

The key to achieving pleasing esthetics in implant dentistry is a thorough understanding of the biological processes driving dimensional bone and soft tissue alterations post-extraction. The aim of the present report is first to characterize the extent of bone and soft tissue changes post-extraction and second to identify potential factors influencing tissue preservation in order to facilitate successful treatment outcomes. The facial bone wall thickness has been identified as the most critical factor influencing bone resorption and can be used as a prognostic tool in order to identify sites at risk for future facial bone loss subsequent to tooth extraction. Clinical studies indicated that thin bone wall phenotypes exhibiting a facial bone wall thickness of 1mm or less revealed progressive bone resorption with a vertical loss of 7.5mm, whereas thick bone wall phenotypes showed only minor bone resorption with a vertical loss of 1.1mm. This is in contrast to the dimensional soft tissue alterations. Thin bone wall phenotypes revealed a spontaneous soft tissue thickening after flapless extraction by a factor of seven, whereas thick bone wall phenotypes showed no significant changes in the soft tissue dimensions after 8weeks of healing. In sites exhibiting a limited bone resorption rate, immediate implant placement may be considered. If such ideal conditions are not present, other timing protocols are recommended to achieve predictable and pleasing esthetics. Socket preservation techniques for ridge preservation utilizing different biomaterials and/or barrier membranes often result in a better maintenance of tissue volumes, although the inevitable biological process of post-extraction bone resorption and bone modeling cannot be arrested. In summary, the knowledge of the biological events driving dimensional tissue alterations post-extraction should be integrated into the comprehensive treatment plan in order to limit tissue loss and to maximize esthetic outcomes.

The relationship between facial bone wall defects and dimensional alterations of the ridge following flapless tooth extraction in the anterior maxilla

To evaluate the relationship between defects of the facial socket wall at extraction and dimensional changes 8weeks later in maxillary central and lateral incisor sockets. A total of 34 consecutive patients requiring single tooth implants in the anterior maxilla (27 central and 7 lateral incisors) were evaluated. Orofacial external ridge, bone dimensions and the location of the socket bone crest were measured at extraction and again 8.5±2.91weeks later. The status of the facial bone wall was recorded at the same time points. At extraction, 16 of 34 sites (47%) had intact facial bone. There were fenestration defects at 9 of 34 sites (26.5%) and dehiscence defects at 9 of 34 sites (26.5%). A significant reduction (P<0.001) in the external orofacial ridge dimension occurred (mesial 1.4±1.30mm or 12.1%, facial 2.5±1.46mm or 22.2%, distal 1.1±0.83mm or 10.5%), with greatest change at dehiscence (3.3±1.80mm or 28.4%) and fenestration sites (2.8±1.40mm or 24.9%). A significant reduction in orofacial bone dimension occurred (mesial 0.8±0.80mm or 9.3%, P<0.001; facial 1.2±1.03mm or 18.3%, P<0.001; distal 0.4±0.65mm or 5.5%, P<0.01). Vertical resorption of the bone crest was most marked at the mid-facial aspect (1.4±1.94mm, P<0.001). Initial fenestration defect sites demonstrated the greatest vertical dimensional change (2.9±2.67mm; P=0.008). Of 16 sites with initially intact facial bone, 9 sites (56.3%) developed dehiscence defects after 8weeks. Of the 9 initial sites with fenestration defects, 5 (55.6%) turned into dehiscence defects. All 9 sites with initial dehiscence defects healed with persistence of the dehiscence. Eight weeks after flapless extraction of maxillary central and lateral incisors, a reduction in the orofacial dimensions of the ridge was observed due to resorption of the facial bone of the socket. Tooth type (maxillary central incisor) and thin tissue phenotype significantly influenced the outcomes. The dimensional alterations were most pronounced at sites that initially had fenestration and dehiscence defects of the facial bone.

Reconstruction of the Alveolar Buccal Bone Plate in Compromised Fresh Socket after Immediate Implant Placement Followed by Immediate Provisionalization.

The aim of this clinical report was to reestablish the buccal bone wall after immediate implant placement. The socket defect was corrected with autogenous bone, and a connective tissue graft was removed from the maxillary tuberosity to increase the thickness, height, and width of the buccal bone and gingival tissue followed by immediate provisionalization of the crown during the same operation. A 66-year-old patient presented with a hopeless maxillary left central incisor with loss of the buccal bone wall. Atraumatic, flapless extraction was performed, and an immediate implant was placed in the extraction socket followed by preparation of an immediate provisional restoration. Subsequently, immediate reconstruction of the buccal bone plate was performed, using the tuberosity as the donor site, to obtain block bone and connective tissue grafts, as well as particulate bone. Finally, immediate provisionalization of the crown followed by simple sutures was performed. Cone-beam computed tomography and periapical radiographs were taken before and after surgery. After 4 months, the final prosthetic crown was made. After a 2-year follow-up, a satisfactory aesthetic result was achieved with lower treatment time and morbidity. This case demonstrates the effective use of immediate reconstruction of the buccal bone wall for the treatment of a hopeless tooth in the maxillary aesthetic area. This procedure efficiently promoted harmonious gingival and bone architecture, recovered lost anatomical structures with sufficient width and thickness, and maintained the stability of the alveolar bone crest in a single procedure. If appropriate clinical conditions exist, immediate dentoalveolar restoration may be the most conservative means of reconstructing the buccal bone wall after immediate implant placement followed by immediate provisionalization with predictable healing and lower treatment time.

Tissue stability of implants placed in fresh extraction sockets: a 5-year prospective single-cohort study.

Several materials have been used for ridge preservation after tooth extraction. This 5-year prospective single-cohort study is aimed at evaluating the success rate, marginal bone level (MBL), soft tissue stability, and subjective patient evaluation of implants placed in fresh extraction sockets with the use of a flapless technique and a xenograft to treat the peri-implant bone defect. Patients requiring a single implant in fresh extraction sockets were selected. After flapless extraction and implant insertion, the peri-implant bone defect was grafted with porcine bone. Collagen membrane was used to stabilize the graft. Four months later, a second surgery and prosthetic procedures were performed. Clinical parameters (width of keratinized gingiva [WKG], facial soft tissue level [FST], papilla index, plaque index, and bleeding on probing) were measured, and periapical radiographs were taken at the time of implant placement (baseline) and then at 1, 3, and 5 years thereafter. Image analysis software was applied to measure changes in the marginal bone level (ΔMBL). Additionally, patient satisfaction regarding the implant treatment was evaluated. All analyses were collected and measured by an independent, trained observer. Together with descriptive statistics, for each of the outcome variables, pairwise comparisons were performed using the Wilcoxon signed-rank test for matched samples. The level of statistical significance was set at 0.01 for all analyses. Forty-seven consecutive patients were treated, with an implant survival rate at 5 years of 95.7%. ΔMBL showed statistically significant differences: mean values were -0.68 ± 0.39, -0.94 ± 0.44, and -1.08 ± 0.43 mm at the 1, 3, and 5-year follow-up, respectively. Changes in WKG (ΔWKG) and FST (ΔFST) decreased from the 1-year point of the survey (0.80 ± 0.79 and 0.71 ± 0.73 mm for ΔWKG and ΔFST, respectively) to the last follow-up check at 5 years (0.67 ± 0.74 and 0.56 ± 0.69 mm for ΔWKG and ΔFST, respectively), with no significant differences. The papilla indexes showed significant differences among the baseline and all the other time points. Concerning patient satisfaction, at the last survey time point, 74% ± 11.8% of patients were satisfied regarding the overall implant treatment, 73.0% ± 11.1% gave a favorable opinion regarding the appearance of the peri-implant soft tissues, and 80.5% ± 11.3% judged positively the finished appearance of the implant crown. No significant differences were obtained among the three follow-up times. The data of the present study suggest that the placement of a dental implant by means of a flapless technique in a fresh extraction socket filled with slowly resorbable graft biomaterial and with a delayed prosthetic restoration shows positive final esthetic outcomes. At the 5-year point of the survey, the changes in the bone level were minimal. Moreover, both midfacial tissue and the papillae maintained the early increase recorded before the first year of the follow-up.

Posterior immediate implant placement with simultaneous crestal approach maxillary sinus bone graft and flapless extraction

membrane) with a mineralized allograft in combination with a roughened titanium tenting screw placed 3-4 mm below the implant platform, and coronal advancement flap. The hard and soft tissues around the implant were evaluated at 6months and approximately 1 year after treatment. Preand post-operative clinical, cone beam computed tomography (CBCT), and restorative cast measurements were made for all patients. Methods of Data Analysis:Descriptive analysis, such as mean and standard deviation (SD) Results: The mean (SD) of pre-operative crestal (2 mm from crest) and mid-implant buccal bone thickness increased from 0.18 (0.45) mm and 0.64 (0.68) mm to 2.02 (0.88) mm and 2.71 (0.34) mm, respectively, approximately one year after treatment. The mean pre-operative soft tissue thickness [measured at implant platform level on study casts or by using CT scan if casts were not available (2)] increased from 1.53 (0.43) mm to 2.81 (0.45) mm. Further, the average width of the labial keratinized tissue improved, from 2.53 (1.26) mm to 3.82 (1.05) mm, and the mean gingival margin height (measured on soft tissue casts with a digital caliper) increased from 1.64 (0.50) mm to 2.87 (0.28) mm. The mean pre-operative tooth length reduced from 10.89 (1.26) mm to 9.64 (0.84) mm (measured using casts). Conclusions: The use of a mineralized allograft with roughened tenting screws and collagen membrane coverage was effective in improving peri-implant soft tissue around ailing implants with gingival recession.

Buccal Bone Formation After Flapless Extraction: A Randomized, Controlled Clinical Trial Comparing Recombinant Human Bone Morphogenetic Protein 2/Absorbable Collagen Carrier and Collagen Sponge Alone

Flapless extraction of teeth allows for undisturbed preservation of the nearby periosteum and a source of osteoprogenitor cells. Recombinant human bone morphogenetic protein 2 (rhBMP-2) has been used for different bone augmentation purposes with great osteoinductive capacity. The aim of this study is to compare the bone regenerative ability of rhBMP-2 on an absorbable collagen sponge (ACS) carrier to a collagen sponge (CS) alone in extraction sites with ≥50% buccal dehiscence. Thirty-nine patients requiring extraction of a hopeless tooth with ≥50% buccal dehiscence were enrolled. After flapless extraction and randomization, either rhBMP-2/ACS carrier or CS alone was placed in the extraction site. After extraction, a baseline cone beam computed tomography (CBCT) scan was obtained of the site, and a similar scan was obtained 5 months postoperatively. Medical imaging and viewing software were used to compare the baseline and 5-month postoperative images of the study site and assess ridge width measurements, vertical height changes, and buccal plate regeneration. Radiographically, CBCT analysis showed that with ≥50% of buccal bone destruction, rhBMP-2/ACS was able to regenerate a portion of the lost buccal plate, maintain theoretical ridge dimensions, and allow for implant placement 5 months after extraction. The test group performed significantly (P <0.05) better in regard to clinical buccal plate regeneration (4.75 versus 1.85 mm), clinical ridge width at 5 months (6.0 versus 4.62 mm), and radiographic ridge width at 3 mm from the alveolar crest (6.17 versus 4.48 mm) after molar exclusion. There was also significantly (P <0.05) less remaining buccal dehiscence, both clinically (6.81 versus 10.0 mm) and radiographically (3.42 versus 5.16 mm), at 5 months in the test group. Significantly (P <0.05) more implants were placed in the test group without the need for additional augmentation. The mean loss in vertical ridge height (lingual/palatal) was less in the test sites but was not significantly (P = 0.514) different between the test and control groups (0.39 versus 0.64 mm). rhBMP-2/ACS compared to CS alone used in flapless extraction sites with a buccal dehiscence is able to regenerate lost buccal plate, maintain theoretical ridge dimensions, and allow for implant placement 5 months later.

Soft Tissue Preservation and Pink Aesthetics around Single Immediate Implant Restorations: A 1‐Year Prospective Study

(1) To document soft tissue aspects using a specific protocol for immediate implant treatment (IIT) following single-tooth removal; (2) to evaluate whether this protocol allows preservation of pink aesthetics as objectively assessed. Patients with a thick gingival biotype and intact buccal bone wall upon extraction of a single tooth in the aesthetic zone (15-25) were consecutively treated. The protocol included flapless extraction and implant surgery, socket grafting, immediate nonocclusal loading with a screw-retained provisional crown, and replacement by a permanent crown 6 months thereafter. The outcome was assessed after 3, 6, and 12 months. Cases demonstrating major alveolar process remodeling and/or advanced midfacial recession (>1 mm) at 3 months were additionally treated with a connective tissue graft (CTG). The emergence profile of the provisional crown was replicated for all permanent crowns. Twenty-two patients (12 men, 10 women; mean age 50) were treated after tooth extraction for nonperiodontal reasons using a novel bone condensing implant with variable-thread design, conical connection, and platform switch (NobelActive®, Nobel Biocare, Göteborg, Sweden). One implant failed and mean marginal bone loss was 0.1 mm (p = .059). Temporary mesial papilla reduction occurred, whereas distal papilla reduction was permanent (mean 0.5 mm; p = .001). At 3 months, five cases demonstrated major alveolar process remodeling and two advanced midfacial recession. Hence, slight initial decline in the pink esthetic score (PES) (p = .053) was observed. CTG resulted in a steady improvement of the PES after 3 months (p ≤ .037). At 12 months, pink aesthetics (mean PES 12.15) was comparable to the preoperative status (mean PES 11.86; p = .293). Distal papillae had significantly deteriorated (p = .020) in this time span, whereas midfacial contour had significantly improved (p = .005). Preservation of pink aesthetics is possible following IIT. However, to achieve that, CTG may be necessary in about one-third of the patients. Major alveolar process remodeling is the main reason for additional treatment.

Vertical and horizontal ridge alterations after tooth extraction in the dog: flap vs. flapless surgery

To compare ridge alterations after flap and flapless tooth extraction in the vertical and horizontal dimension in the dog model. This study was carried out on five Beagle dogs. Four extractions were performed in the lower jaw of each dog (two per side. Pm3, Pm4). At the time of tooth extraction, flap surgery was performed on one side (control group). On the contra-lateral side, a flapless extraction was performed (test group). Mesial sockets were left untreated on both sides. After 3 months of healing, the dogs were sacrificed and prepared for histological analysis. Ten samples were evaluated on each group. The vertical difference in height between the buccal and lingual crest was 1.48 mm for the flap, and 1.22 mm for the flapless group. The horizontal dimension of the ridge was 4.41 mm (at 1 mm from the crest), 5.72 mm (at 3 mm from the crest) and 6.67 mm (at 5 mm form the crest) in the flap group. In the flapless group, the measurements were 4.5, 5.58 mm and 6.44 at 1, 3 and 5 mm from the crest, respectively. Evaluating ridge alterations in the vertical and horizontal dimension after 3 months of healing following tooth extraction, results for the flap and the flapless group were very similar.

A Comparative Study on the Extractions of Partially Impacted Mandibular Third Molars With or Without a Buccal Flap: A Prospective Study

The present report describes a flapless extraction method for partially impacted mandibular third molars and compares the effects of flap and flapless extractions of the teeth in terms of postoperative pain, swelling, and pocket depth of the second molar. A prospective study was performed of 27 patients who underwent bilateral extraction of partially impacted mandibular third molars. Two molars in the same patient were extracted on each side, either with or without a buccal flap. The postoperative pain, swelling, and pocket depth of the second molar were all significantly greater on the side that underwent flap extraction than on the side that underwent flapless extraction (P < .05). Our results support the clinical use of flapless extractions when the distal surface of the crown is completely anterior to the anterior border of the mandibular ramus and the occlusal surface of the impacted tooth is level or nearly level with the occlusal plane of the second molar.

Ridge alterations following tooth extraction with and without flap elevation: an experimental study in the dog

Different approaches were advocated to preserve or improve the dimension and contour of the ridge following tooth extraction. In some of studies, socket 'flapless extraction' apparently had a successful outcome. The objective of the present experiment was to compare hard tissue healing following tooth extraction with or without the prior elevation of mucosal full-thickness flaps. Five mongrel dogs were used. The two second mandibular premolars ((2)P(2)) were hemi-sected. The mesial roots were retained. By random selection the distal root in one side was removed after the elevation of full-thickness flaps while on the contralateral side, root extraction was performed in a flapless procedure. The soft tissue wound was closed with interrupted sutures. After 6 months of healing, the dogs were euthanized and biopsies were sampled. From each experimental site, four ground sections - two from the mesial root and two from the healed socket - were prepared, stained and examined in the microscope. The data showed that the removal of a single tooth (root) during healing caused a marked change in the edentulous ridge. In the apical and middle portions of the socket site minor dimensional alterations occurred while in the coronal portion of the ridge the reduction of the hard tissue volume was substantial. Similar amounts of hard tissue loss occurred during healing irrespective of the procedure used to remove the tooth was, i.e. flapless or following flap elevation. Tooth loss (extraction) resulted in marked alterations of the ridge. The size of the alveolar process was reduced. The procedure used for tooth extraction - flapless or following flap elevation - apparently did not influence the more long-term outcome of healing.