Socket Grafting Research Articles

Autogenous Options for Soft‐Tissue Management of Extraction Sockets in the Anterior Maxilla

Focused Clinical Question: How can the soft tissue be managed with autogenous options after tooth extraction in the anterior maxilla?Summary: Esthetic concerns are of unique importance in the anterior maxilla. Tooth loss usually leads to significant alterations of the soft‐ and hard‐tissue components of the ridge. These alterations may be prevented or minimized by a variety of tissue augmentation methods at different time points, ranging from tooth extraction to the placement of a restoration. Autogenous soft‐tissue options are available to achieve complete closure of socket grafting and immediate implant sites. They comprise free gingival grafts, free connective tissue grafts, pedicle palatal tissue grafts, and coronally advanced flaps. A decision tree is presented for the different hard‐ and soft‐tissue management options after tooth extraction in the anterior maxilla.Conclusions: The literature lacks comparative studies among the different soft‐tissue grafting techniques designed for soft‐tissue closure of extraction sockets. Nonetheless, full closure is recognized as an important hallmark for improved healing outcomes. Soft‐tissue augmentation and volume increase were clinically evident with the various techniques. The minimal adverse healing events and improved survival reported with the pedicle grafts tend to favor these options in socket preservation cases, whereas coronally advanced flaps are preferred in severe cases involving multiple sockets.

Current perspectives on the role of ridge (socket) preservation procedures in dental implant treatment in the aesthetic zone

Augmentation of the extraction socket (ridge preservation) is increasingly being advocated in anticipation of implant placement. The aim of this article is to review the available evidence with regards to ridge preservation procedures, investigating whether these techniques improve dental implant treatment outcomes. Evidence is examined to compare these techniques to other treatment alternatives such as implant placement with simultaneous lateral augmentation. An electronic PubMed search was conducted using search terms relevant to assessing treatment outcomes in association with ridge preservation. Titles were screened and full text obtained where relevant. Further full text articles were obtained from analysis of those papers yielded from the original search. Twenty-two papers were finally selected for analysis. Ridge preservation techniques are effective in minimizing post-extraction alveolar ridge contraction. However, there is insufficient evidence to suggest that the use of these techniques in conjunction with dental implant treatment improves implant treatment outcomes. Furthermore, ridge preservation does not necessarily eliminate the need for further simultaneous augmentation at the time of implant placement. The delayed healing associated with ridge preservation using socket grafting necessitates a commitment to a delayed placement protocol. The extended treatment time, compromised healing and expense related to ridge preservation suggests a more cautious approach with regards to the indication of such techniques.

Characteristics of Newly Formed Bone in Sockets Augmented With Cancellous Porous Bovine Bone and a Resorbable Membrane

Microcomputed tomography (micro-CT) has become a highly accurate and nonintrusive method for analysis of bone. This study aims to determine the microstructural characteristics of the bone formed in grafted extraction sockets. This prospective study comprised 10 patients. Cancellous porous bovine bone (CPBB) was used for socket grafting. Ten bone samples were harvested from implant site 9 months after grafting, before implant placement, and histologic and microstructural characteristics were analyzed. Cone-beam computed tomography scans were performed, and implant stability was also determined. Four men and 6 women, with a mean age of 44 years, were included in the study. Micro-CT revealed a compact structure with high bone volume fraction, trabecular thickness and number, but a low trabecular separation and pattern factor, which made it an optimal structure that is expected to resist occlusal loads. Histologic examination revealed an abundant amount of CPBB particles (27.5%) and new bone formation (23.3%) 40.6 months after bone grafting surgery. Moreover, mean implant stability quotient was 75.7 units. This investigation demonstrated marked de novo bone formation after a healing period of 9 months. This trabecular bone had a compact structure with abundant thick trabeculae.

Guided Bone Regeneration for Socket Preservation in Molar Extraction Sites: Histomorphometric and 3D Computerized Tomography Analysis

Guided Bone Regeneration for Socket Preservation in Molar Extraction Sites: Histomorphometric and 3D Computerized Tomography Analysis

Use of Cuban Granulated Β-Tricalcium Phosphate “Biograft-G” as Maxilar Bone Graft

In maxillary bone, several pathologies or lesions may cause maxillary alveolar atrophic (MAA), that is, a bone reabsorption frequently provoked by tooth loses or extractions. Tooth loses or extractions are one of the most common clinical situations observed in patients. The MAA could become a signifi cant functional and aesthetic risk for the use of tooth implants or any other prosthetic rehabilitation. Several biomaterials have been used as bone graft; they must fulfi l requirements like biocompatibility and a suitable function. A synthetic dense ceramic granulate of β-TCP, BIOGRAFT-G® (BIOMAT), in form of irregular shape granules with a grain size between 0.1 mm and 0.4 mm, was used in this study as graft material. The clinical studies include 178 patients, treated in Pre-implantology and Trans-implantology bone remodelling, prevention of residual ridge reabsorption by socket grafting and Periapical Surgical. In the fi nal evaluation of effectiveness after 6 month of surgery most of cases were qualifi ed as Success (98.3%), observing in the treated site a remodeled bone similar to the one in the adjacent tissue and almost no trace of implanted biomaterial. However, 3 cases were qualifi ed as Failure, all of them in patients that underwent the fi lling of dental sockets treatment, caused by the exfoliation of granules or a septic process. According to the obtained results, Biograft-G® proved to be a biodegradable, biocompatible, effectiveness and safety bone graft biomaterial in the studied treatments.

Closure of 1.5-cm Alveolar Oral Antral Fistula with Intra-alveolar Sinus Membrane Elevation and Bone Morphogenetic Protein-2/Collagen Graft Followed by Dental Implant Restoration: Case Report

Closure of a 1.5-cm oral antral fistula was done in combination with sinus floor and extraction socket grafting using recombinant human bone morphogenetic protein-2 within a collagen sponge matrix. The approach to the sinus was transalveolar, with elevation of the sinus membrane done through a molar extraction socket. Following graft placement, soft tissue repair was done with a buccal advancement flap. A dental implant was subsequently placed and restored. Peri-implant bone and implant stability were well maintained at the 1-year follow up examination.

Efficacy of using a dual layer of membrane (dPTFE placed over collagen) for ridge preservation in fresh extraction sites: a micro‐computed tomographic study in dogs

To assess if overbuilding the buccal plate or using a dual-layer socket grafting technique prevents alveolar bone resorption and enhances final ridge width, height, and volume after tooth loss in an animal model. In eight beagle dogs bilateral second (P2)-, third (P3)-, and fourth (P4) premolars were endodontically treated. All bilateral mandibular first premolars and distal roots of P2, P3, and P4 were hemisectioned and atraumatically extracted. Animals were randomly divided into four groups: (i) Control-Socket alone, (ii) Particulate allograft in the alveolum, socket covered with high-density polytetrafluoroethylene (dPTFE) membrane and sutured over the alveolum, (iii) Particulate allograft in the alveolum and overbuilding the buccal plate, socket covered with dPTFE membrane and sutured over the alveolum, (iv) Particulate allograft in the alveolum and covered with dual layer (dPTFE placed over collagen membrane), and sutured over the alveolum. After 16 weeks, the animals were sacrificed. Mandibular blocks of the jaws were assessed for bone volume (BV), vertical bone height (VBH), alveolar ridge thickness, and bone mineral density (BMD) using micro-computed tomography. The BV in groups 1, 2, 3, and 4 was 169.5, 207.57, 242.4, and 306.1 mm(3) , respectively. The VBH in groups 1, 2, 3, and 4 was 4.2, 6.4, 6.2, and 7.3 mm, respectively. Ridge widths in groups 1, 2, 3, and 4 were 5.45 ± 0.75, 5.91 ± 0.86, 6.05 ± 0.63, and 6.28 ± 1.01 mm, respectively. There was no significant difference in BMD between the groups. The RP using a dual layer of membrane following tooth extraction results in more BV, VBH, and alveolar ridge width as compared to when a single layer of membrane is used.

Three dimensional socket preservation: a technique for soft tissue augmentation along with socket grafting

BackgroundA cursory review of the current socket preservation literatures well depicts the necessity of further esthetic considerations through the corrective procedures of the alveolar ridge upon and post extraction. A new technique has been described here is a rotational pedicle combined epithelialized and connective tissue graft (RPC graft) adjunct with immediate guided tissue regeneration (GBR) procedure.ResultsWe reviewed this technique through a case report and discuss it’s benefit in compare to other socket preservation procedures.ConclusionThe main advantages of RPC graft would be summarized as follows: stable primary closure during bone remodeling, saving or crating sufficient vestibular depth, making adequate keratinized gingiva on the buccal surface, and being esthetically pleasant.

Indirect restoration use: A changing paradigm

Only a few innovations in my long professional history have met with rapid acceptance after their introduction to the dental marketplace. Among them are air-rotor handpieces, resin-based composite, porcelain-fused-to-metal restorations, any material or technique that could be identified as “esthetic― or “cosmetic,― rotary endodontic instruments, ultrasonic scalers, magnifying loupes and digital photography. However, many other advancements or new concepts that seem to have advantages have received relatively slow acceptance from the profession—such as in-office milling of restorations, digital radiography, use of clinical microscopes, socket grafting and automated periodontal pocket probing.

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.

Postextraction Alveolar Ridge Preservation: Biological Basis and Treatments

Following tooth extraction, the alveolar ridge undergoes an inevitable remodeling process that influences implant therapy of the edentulous area. Socket grafting is a commonly adopted therapy for the preservation of alveolar bone structures in combination or not with immediate implant placement although the biological bases lying behind this treatment modality are not fully understood and often misinterpreted. This review is intended to clarify the literature support to socket grafting in order to provide practitioners with valid tools to make a conscious decision of when and why to recommend this therapy.

Socket Preservation with Alloplast: Discussion and a Descriptive Case

Soon after tooth extraction the bone resorption takes place reducing the height and width of alveolar ridge. This produces an altered morphology of the bone unfavorable for implant placement and implant placement becomes impossible without surgical correction. Socket grafting maintains and preserves ridge for implant placement.

Reviews of Current Literature

Lozada JL, Goodacre C, Al-ardah AJ, Garbadea A. Lateral and crestal bone planing antrostomy: a simplified surgical procedure to reduce the incidence of membrane perforation during maxillary sinus augmentation procedures. J Prosthet Dent. 2011;105:147–153.This clinical report of 2 patients presents a variation to conventional surgical techniques for opening the maxillary sinus antrum via lateral and crestal approaches. This procedure, described as a lateral/crestal bone planing antrostomy (LBPA, CBPA) involves the use of specially designed rotary instruments that plane away the bone in thin layers. This technique has the potential to reduce the perforation rate of the maxillary sinus membrane during the access process. The authors provide a good review of conventional lateral wall and crestal access techniques and discussion concerning the most common surgical complication of sinus membrane perforation. Two clinical case reports (one LBPA and one CBPA) with detailed stepwise procedural details are presented using bone planing. Excellent color photographs enhance the reader's ability to understand the surgical process.These case reports provide an interesting alternative to existing techniques, however controlled clinical studies with randomized designs are needed before a definitive conclusion can be drawn concerning wide spread acceptance of the technique.James L. RutkowskiEditor-in-Chief, Journal of Oral ImplantologyChairman, Clarion Research GroupFellow AAIDDiplomat ABOI/IDSilverstein LH, Kurtzman D, Shatz PC. Principles of Hard Tissue Regeneration and Implant Therapy: A Complete Step-by-Step Guide. Newton, Pa: Aegis Communications.This textbook is a comprehensive step-by-step manual available to teach surgical hard tissue regeneration for implant dentistry including: socket grafting, ridge augmentation, and maxillary subantral augmentation using either a Caldwel-Luc or crestal approach. The authors describe each procedure in detail with 7 layered animation type visual technology illustrations. One such procedure illustrated describes how to split a posterior ridge for facial expansion and an anterior ridge labially. Instructions are provided on “how-to-do” mono cortical ridge grafting with either the ramus or symphysis as the donor site. Multiple grafting techniques are covered.Readers are shown all steps for each procedure, from administering local anesthetic, to the specific surgical blades, blade angles, sites, and parameters of where the incisions should be made. All surgical procedural steps are explained in detail with corresponding illustrations. Each procedure details the description of suturing; which needles, threads, surgical knots, and specific techniques to use. Specific postoperative instruction sheets are provided that can be copied and given to the patient.The text was refereed and has received CERP accreditation. After successful completion of the test located at the back of the book and proper submission of the CE form, the clinician will receive three hours of Continuing Education credit.This textbook provides a thorough step-by-step outline for multiple hard tissue regeneration procedures as they apply to implant dentistry and should be a well-used reference by all clinicians. This is a must-have text for the Implant Dentist's library.James L. RutkowskiEditor-in-Chief, Journal of Oral ImplantologyChairman, Clarion Research GroupFellow AAIDDiplomat ABOI/ID

Radiographic alveolar bone changes following ridge preservation with two different biomaterials

The aim of this randomized controlled trial was to evaluate radiographical bone changes following alveolar ridge preservation with a synthetic bone substitute or a bovine xenograft. Alveolar ridge preservation was performed in 27 patients randomized in two groups. In the test group (n=14), the extraction socket was treated with Straumann bone ceramic(®) (SBC) and a collagen barrier membrane (Bio-Gide(®)), whereas in the control group (n=13) with deproteinized bovine bone mineral and the same barrier. Standardized periapical X-rays were taken at 4 time points, BL: after tooth extraction, GR: immediately after socket grafting, 4M: 16 weeks, 8M: 32 weeks post-operatively. The levels of the alveolar bone crest at the mesial (Mh), and distal (Dh) and central aspects of the socket were measured at all time points. All the radiographs obtained were subtracted from the follow-up images. The gain, loss and unchanged areas in terms of grey values were tested for significant difference between the two groups. In the test group, the Mh and Dh showed a mean difference (± standard deviation) of 0.9 ± 1.2 and 0.7 ± 1.8 mm, respectively, among BL-8M. In the control group, the Mh and Dh showed a mean difference of 0.4 ± 1.3 and 0.7 ± 1.3 mm, respectively (P>0.05). Both treatments presented similar gain in grey values between BL-GR, BL-4M and BL-8M. The SBC presented less loss in grey values between BL-4M and BL-8M (P<0.05). Radiographic assessment underestimated the intrasurgical measurements (mesial and distal) of an average 0.3 mm (95% CI, 0.02-0.6). Both types of bone grafts presented similar radiographic alveolar bone changes when used for alveolar ridge preservation.

Socket grafting with the use of autologous bone: an experimental study in the dog

studies in humans and animals have shown that following tooth removal (loss), the alveolar ridge becomes markedly reduced. Attempts made to counteract such ridge diminution by installing implants in the fresh extraction sockets were not successful, while socket grafting with anorganic bovine bone mineral prevented ridge contraction. to examine whether grafting of the alveolar socket with the use of chips of autologous bone may allow ridge preservation following tooth extraction. in five beagle dogs, the distal roots of the third and fourth mandibular premolars were removed. The sockets in the right or the left jaw quadrant were grafted with either anorganic bovine bone or with chips of autologous bone harvested from the buccal bone plate. After 3 months of healing, biopsies of the experimental sites were sampled, prepared for buccal-lingual ground sections and examined with respect to size and composition. it was observed that the majority of the autologous bone chips during healing had been resorbed and that the graft apparently did not interfere with socket healing or processes that resulted in ridge resorption. autologous bone chips placed in the fresh extraction socket will (i) neither stimulate nor retard new bone formation and (ii) not prevent ridge resorption that occurs during healing following tooth extraction.

Alveoar bone augmentation: histological evaluation of graft remodelling correlated to volumetric ridge alteration

After tooth extraction the alveolar bone undergoes a remodeling process resulting in an overall bone volume reduction. Several studies showed that socket grafting limits the alveolar ridge remodeling. Furthermore studies showed that the grafting material is involved in a partial remodeling process and that the remodeling time extends for years. Aim of the present study was to evaluate the correlation between graft remodeling and volumetric ridge alteration. Materials and Methods Seven extraction sockets were grafted with Bio-Oss collagen and 8 extraction sockets were left untreated. At baseline, 3 and 6 months post extraction alveolar ridge dimensional changes were evaluated on all sites: an acrylic stent was prepared for each patient and measurements from the alveolar bone to the stent were taken using a periodontal probe PCP UNC 15 (Hu-Friedy). Histological analyses on newly formed bone were performed on one specimen from augmented sites after 3 and 6 months post extraction. Results Untreated alveolar socket showed a stronger volumetric reduction compared to grafted socket. At histological evaluation the slow remodeling process of the graft material was confirmed. At 3 months, bone density was 2.77%, residual Bio-Oss Collagen amounted to 43.75%, and connective tissue was 53.48%. At 6 months, the harvested cylinder was comprised of 44.42% new bone, 12.50% grafted Bio-Oss Collagen and 43.08% connective tissue/ bone marrow. Conclusions The slow remodeling process of graft material seems to contrast the fast remodeling of the blood clot and the alveolar bone resorption, thus compensating the alveolar ridge contraction.

Bone crestal height and bone density after third-molar extraction and grafting: a long-term follow-up study

The objective of this study was to evaluate the long-term influence of xenogenic grafts on bone crestal height and radiographic density following extraction of teeth. The right and left third lower molars of 22 patients were surgically extracted, and one randomly chosen socket was filled with a xenogenic graft (Gent-Tech). The contralateral molar was left to heal naturally, serving as a paired control. Digital intraoral radiographies were taken at surgery and 2, 6, and 24months after, to evaluate bone density (BD) and alveolar bone crest to cementoenamel junction distance. The data obtained were subjected to two-way analysis of variance and Tukey's test (α = 0.05). The significant decrease in cementoenamel junction distance observed for both groups was limited to the first 6months. BD values increased significantly in the first 6months, with no alterations observed up to 24months for both groups. BD was higher for the experimental group at all time points (p < 0.05). Socket grafting with the xenogenic materials tested did not changed bone crestal height and bone radiographic density in the long term.

Prospective Evaluation of Immediate and Delayed Provisional Single Tooth Restorations

The purpose of this study was 2-fold: to determine whether there is a significant difference in the hard and soft tissue response comparing immediate with delayed implant placement after tooth removal, with immediate provisionalization, in maxillary anterior sites; and to determine and compare the crestal bone levels as the primary endpoint variable for implants placed and immediately temporized in extraction sites, to implants placed into extraction sites after the extraction site has been grafted and healed for 4 months, all immediately restored with an anatomic provisional restoration. This aim was to be evaluated by measuring crestal bone levels on standardized digital radiographs of the implants, using implant threads as a monitor of magnification and a pre-extraction reference. Secondary endpoint variables include soft tissue measures compared with method. A total of 76 patients were recruited and randomized into treatment groups. Group 1 had a maxillary tooth (premolar, canine, lateral or central incisor) removed, with immediate socket grafting, followed by implant placement and provisionalization 4 months later with a single tooth. Group 2 had immediate implant placement and provisionalization. Standardized radiograph holders were used to expose digital radiographs every 6 months from baseline to up to 2 years restored. Soft tissue measures were made from standardized reference points. Data collected were analyzed by a statistician to test the hypotheses. A total of 55 patients completed their follow-up. Twenty-one patients were lost to follow-up because of implant loss (n = 5), 1 treated out of protocol because of labial bone loss found at the time of tooth removal (n = 1), geographic relocation (n = 11), dropped for noncompliance (n = 3), or medical problems (n = 1). The analyses showed no significant differences between groups in implant integration or crestal interdental bone movement on either the implant or the adjacent tooth. The bone level on the implants did move from the baseline levels during the first 6 months but not thereafter. There were no differences (P > .05) observed when comparing the interactions between groups, tooth locations, or time. There was a significant (P < .05) difference in the position of the facial gingival margin with a more apical position of the facial gingival margin in the delayed group compared with the immediate group during the course of the study. Crestal bone response to immediate or delayed placement of an implant into an extraction site in the maxillary anterior region with immediate provisionalization is similar regarding hard tissue changes. Support of the gingival margin with a provisional at the time of tooth extraction and implant placement preserved 1 mm more facial gingival margin position compared with the delayed group. The decision to use either method must consider the movement of the facial gingival margin, which, in a critical esthetic patient may require soft tissue support from a provisional restoration or similar type of anatomical healing abutment.

P.057 Bisphosphonate induced osteonecrosis: surgical case reports

As socket grafting with commercially available biomaterials has become popular, reports of the root submergence technique for ridge preservation have decreased. A systematic review of this partial extraction therapy is lacking.The purpose of this systematic review was to review the root submergence technique as well as critically appraise the available data.A review was carried out that observed the Participant, Intervention, Comparison, Outcomes (PICO) strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The focused question was “What are the outcomes of the different methods to submerge tooth roots for ridge preservation?” Medical subject headings (MeSH) terms that related to the root submergence technique were searched in PubMed/MEDLINE, Scopus, and the Cochrane Library databases.A total of 7709 abstracts and study titles were individually screened from the initial search results. After reviewing the full-text articles and applying the selection criteria, the final included search results totaled 47 full-text articles for in-depth review. In 10 animal studies, 258 roots were studied in 34 dogs and 7 monkeys. Histological data confirmed that coronal bridging (bone or cementum growth over the cut root) was a common outcome. Of the vital roots submerged, the majority maintained their vitality. In 37 human studies, 475 roots were submerged and reported on. Subjective ridge preservation was often reported. Among the adverse healing outcomes, exposure of the root through the mucosa was the most common. Nonetheless, in animals, 86.8% of roots remained submerged; in humans, 74.7%.Root submergence is an established technique for ridge preservation. Exposure is a common complication, and correct technique may be key to its prevention. Further research of this partial extraction therapy is encouraged.

Socket Grafting: A Predictable Technique for Site Preservation

The demand for dental implants continues to rise worldwide, requiring clinicians to consider the incorporation of bone preservation procedures into their dental practice. Socket grafting offers a predictable, simple way to conserve the buccolingual and mesiodistal dimensions of the future implant site. Careful bone management and the use of various bone-grafting materials must be part of the practice of every implantologist. In this case report, the authors present a fundamental technique for socket grafting and 3 cases of site preservation with subsequent implant placement and restoration. Emphasis is placed on the evidence-based rationale for this procedure, the clinical technique, and the various grafting materials that can be employed by the clinician.