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Are socket and ridge preservation techniques at the day of tooth extraction efficient in maintaining the tissues of the alveolar ridge? – Systematic review, consensus statements and recommendations of the 1st DGI Consensus Conference in September 2010, Aerzen, Germany
Abstract
Purpose: In recent years questions have arisen whether extraction sockets of future implant sites should be treated differently than sockets where no implant therapy will be done in the future. It was the aim of this systematic review to provide a basis for an expert consensus on the current status of socket preservation (SP) and ridge preservation (RP) procedures at the day of tooth extraction.
Materials and methods: A systematic literature search was performed in PubMed and in selected journals by hand, covering the years 1981 to 31 July 2010. Only prospective controlled studies in humans with or without randomisation were included. The control groups had to consist of an untreated extraction socket, and clinical or radiographic measurements of the ridge dimensions after extraction and after the respective healing time were required. Weighted means were calculated and compared.
Results: Ten studies met all inclusion criteria and could be evaluated in detail. Horizontal ridge loss was reduced by 59%, and vertical ridge loss by 109%, if SP/RP was applied after tooth extraction. The need for hard tissue augmentation at implant placement was five times higher, if no SP/RP was performed on the day of tooth extraction.
Conclusions: SP/RP seems to be effective in maintaining ridge dimensions after tooth extraction. No recommendations for a specific technique or material can be made yet. Further studies are needed to clarify these issues.
... With the advent of a growing array of choices in materials, there is much interest in the best material and technique for ARP. No less than ten systematic reviews on the subject have been published since 2009, 1,3,7,8,9,10,11,12,13,14 and the literature does not support the use of one technique, or material, as superior. ...
... Membranes and bone substitutes may, 6,7,8,12,74 or may not, 3,13,14,75 preserve more bone than bone substitutes alone, but it must be emphasised that the difference is not clinically significant. ...
... The need for primary closure to improve ARP outcomes is debatable from the literature, with some authors presenting results in favour of socket sealing, 6,7,8,12 while others presenting results not in favour. 3,13,14,75 However, particulate bone substitutes could easily become dislodged from extraction sockets, and some resorbable membranes An alternative technique is to use the hard palate to provide access to free and pedicle grafts. Free gingival grafts can be harvested with soft tissue punches of the appropriate size to cover the socket. ...
Alveolar ridge preservation (ARP) is a method of decreasing bone resorption following tooth extraction and facilitating prosthetically-driven implant placement. An understanding of the physiological responses occurring after extraction and the effects of ARP are important in order to implement clinical procedures. ARP is a predictable way to reduce undesirable horizontal and vertical ridge reduction following extraction when dental implant treatment is to be delayed. Guided bone regeneration, socket fillers, socket sealers and growth factors have been used satisfactorily. However, there is currently no consensus on case selection, best clinical technique and material choice. Management of tooth extraction sockets is presented, with a focus on decision-making.
... According to Sclar (2004), the aforementioned term represents "all surgical techniques that aim to preserve the maximum volume and architecture of hard and soft tissues in the extraction site, in order to optimize the aesthetics and function of the future implant-supported restoration". For authors such as Weng., et al. (2011), when the ridge is not properly preserved, a smaller amount of healthy bone can be found, resulting in inadequate aesthetics in the region and leading to the need for bone grafting, which in the posterior region has a 10 times higher prevalence during rehabilitation, compared to treatment with prior ridge preservation [15,16]. Bezerra., et al. (2021) concluded in their study that the alveolar ridge is preserved and bone volume is maintained when applying the double layer membrane technique after tooth extraction, noting that this preservation is of paramount importance for good peri-implant health, as well as for a longer immediate implant survival rate. ...
... According to Sclar (2004), the aforementioned term represents "all surgical techniques that aim to preserve the maximum volume and architecture of hard and soft tissues in the extraction site, in order to optimize the aesthetics and function of the future implant-supported restoration". For authors such as Weng., et al. (2011), when the ridge is not properly preserved, a smaller amount of healthy bone can be found, resulting in inadequate aesthetics in the region and leading to the need for bone grafting, which in the posterior region has a 10 times higher prevalence during rehabilitation, compared to treatment with prior ridge preservation [15,16]. Bezerra., et al. (2021) concluded in their study that the alveolar ridge is preserved and bone volume is maintained when applying the double layer membrane technique after tooth extraction, noting that this preservation is of paramount importance for good peri-implant health, as well as for a longer immediate implant survival rate. ...
... In an attempt to attenuate the resorption events that follow tooth loss and to minimize the need for ancillary ridge augmentation procedures prior to delivery of dental implant socket preservation technique has been proposed. Where, socket preservation helps to maintain the alveolar ridge architecture and significantly reduces the external changes (4)(5)(6)(7) . ...
... These morphologic changes pose significant challenges in restorative treatment, as soft tissue recession and buccal plate resorption define the anatomical profile of the socket and may narrow the viable treatment options. (22) Accordingly, reconstructions of resorbed alveolar ridges and alveolar ridge preservation have been a goals and challenges of clinicians to create an anticipated foundation for implant placement to optimize the outcomes (4)(5)(6)(7) . ...
... e use of these regenerative materials was proposed when the size of the residual bone defect exceeded a 1 to 2 mm threshold of horizontal gap between the implant surface and the buccal bony wall. Several authors recommended the use of bone graft in such cases [14][15][16]. However, the validity of this "dimension" has never been conclusively demonstrated, leading other studies to suggest that such bone defects could heal clinically without any bone regeneration procedures or grafting materials [8,17]. ...
... Two studies were assessed as high risk of attrition bias [6,24] due to performing per-protocol analysis. e remaining four trials included all randomised participants and were at low risk of attrition bias [5,14,21,26]. All included trials were at high risk of reporting bias. ...
Purpose
To assess the effects of augmentation versus no augmentation in patients restored with immediate postextraction single-tooth implants on implant failure and patient satisfaction.
Materials and methods
We searched the Cochrane Oral Health Group Trial Register, Cochrane Central Register of Controlled Trials, MEDLINE, and the WHO International Clinical Trial Registry Platform (22 March 2017). Two reviewers independently assessed trials for inclusion and risk of bias, extracted data, and checked for accuracy. We have expressed results as risk ratio or mean differences, together with their 95% confidence intervals.
Results
We included six studies (287 participants). Two trials compared no augmentation versus bone graft augmentation and reported no implant failures in both groups after a follow-up period of 6 months (20 implants) and 1 year (34 implants). One trial compared bone graft augmentation versus membrane augmentation and reported no difference in implant failure between both groups after 6 months (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.06 to 15.31) or 1 year of follow-up (RR 0.33, 95% CI 0.01 to 7.86), and no implants were lost after 3 years. Three trials compared membrane augmentation versus combined bone graft and membrane augmentation, and there was no difference between the groups after six months of follow-up in implant failure (RR 5.13, 95% CI 0.63 to 41.93) or after 1 year (RR 0.38, 95% CI 0.02 to 9.05). There was insufficient evidence regarding patient satisfaction in all the included trials.
Conclusions
In patients restored with immediate postextraction single-tooth implants, there is insufficient evidence to recommend simultaneous augmentation or a certain augmentation protocol to enhance implant survival and patient satisfaction. This trial is registered with PROSPERO (CRD42017054439).
... In the present study, all sites were fully covered with newly formed keratinized soft tissue while the buccal keratinized soft tissues were preserved. As the presence of an adequate zone of keratinized gingiva is an important parameter in achieving esthetic implant restorations [26], preventing future mucosal recessions, and improving the overall long-term implant stability, the use of flapless techniques by taking advantage of the biomechanical properties of in situ hardening alloplastic grafts seems to be a benefit for the clinicians and patients when applicable. ...
... In all patients, the dimensions of the ridge were adequately preserved at the time of implant placement (5.1 ± 2 months) and bone resorption was marginal. Mean ridge width reduction assessed by CBCT was 0.79 ± 0.73 mm (Table 2), which is well below the results reported for ridge preservation techniques using both bone substitute material in combination with membranes or soft tissue grafts [26,27]. A recent meta-analysis [27] further suggested that the choice of the biomaterial did not have a significant influence on the ridge preservation after tooth extraction and that all materials sufficiently maintained the ridge dimensions. ...
Background
Post-Extraction ridge preservation using bone graft substitutes is a conservative technique to maintain the width of the alveolar ridge. The objective of the present study was to evaluate an in situ hardening biphasic (HA/β-TCP) bone graft substitutes for ridge preservation without primary wound closure or a dental membrane.
Methods
A total of 15 patients reported for tooth extraction were enrolled in this study. Implants were placed in average 5.2 ± 2 months after socket grafting. At this visit, Cone Beam CT (CBCT) images and core biopsies were taken. Implant stability (ISQ) was assessed at the insertion as well as at the day of final restoration.
Results
CBCT data revealed 0.79 ± 0.73 mm ridge width reduction from grafting to implant placement. Histomorphometric analysis of core biopsy samples revealed in average 21.34 ± 9.14% of new bone in the grafted sites. Primary implant stability was high (ISQ levels 70.3 ± 9.6) and further increased until final restoration.
Conclusions
The results of this study show that grafting of intact post-extraction sockets using a biphasic in situ hardening bone graft substitute results in an effective preservation of the ridge contour and sufficient new bone formation in the grafted sites, which is imperative for successful implant placement.
... However, it is possible to minimize such problems by simply carrying out socket preservation procedures in extraction sockets using grafting materials with or without barrier membranes [3,4]. Most importantly, socket preservation helps to maintain the alveolar ridge architecture and significantly reduces the external changes in the form of loss of ridge width and height following tooth removal [5][6][7][8][9] . The result is that more costly secondary augmentation procedures are generally not necessary [7]. ...
... Most importantly, socket preservation helps to maintain the alveolar ridge architecture and significantly reduces the external changes in the form of loss of ridge width and height following tooth removal [5][6][7][8][9] . The result is that more costly secondary augmentation procedures are generally not necessary [7]. At time of implants placement, the site will be more perfect and if bone augmentation is required, then it will be a simpler procedure. ...
The extraction socket preservation technique conserves the alveolar architecture and prevents hard and soft tissue collapse that minimizes the necessity for further augmentation procedures. Also, using platelets concentrate derivatives enriched with growth factors and leukocytes which enhance osteogenic differentiation and bone formation. This article describes socket preservation using autologous concentrated growth factors enriched bone graft matrix (sticky bone).
... 59 In recent years, 13 systematic reviews have addressed the healing of extraction sockets and the dimensional changes (height and width) of the hard and soft tissues of the alveolar ridge. [60][61][62][63][64][65][66][67][68][69][70][71][72] A general consensus among the results of these 13 systematic reviews is that although socket grafting did not completely prevent bone resorption, it appeared to be effective in preserving the alveolar ridge volume compared with extraction alone. Nevertheless, many deficiencies remain from previous 13 systematic reviews. ...
... Additionally, previous systematic reviews have all grouped socket grafting outcomes after flapless and flap surgical approaches of teeth extractions. [60][61][62][63][64][65][66][67][68][69][70][71][72] Flapless approach for teeth extractions is known to be a simple, atraumatic, and conservative method. Various authors have reported improved clinical outcomes with the flapless approach for teeth extractions with reduced healing times, discomfort, and inflammation. ...
Several biomaterials and techniques have been reported for socket grafting and alveolar ridge preservation. However, the evidence for clinical and histologic outcomes for socket grafting with different types of materials in flapless extraction is not clear.
The purpose of this systematic review was to analyze the outcomes of a socket grafting procedure performed with flapless extraction of teeth in order to determine which graft material results in the least loss of socket dimensions, the maximum amount of vital bone, the least remnant graft material, and the least amount of connective tissue after a minimum of 12 weeks of healing. Secondary outcomes, including the predictability of regenerating deficient buccal bone, necessity of barrier membranes, and coverage with autogenous soft tissue graft, were also evaluated.
An electronic search for articles in the English-language literature was performed independently by multiple investigators using a systematic search process with the PubMed search engine. After applying predetermined inclusion and exclusion criteria, the final list of randomized controlled clinical trials (RCTs) for flapless extraction and socket grafting was analyzed to derive results for the various objectives of the study.
The initial electronic search resulted in 2898 titles. The systematic application of inclusion and exclusion criteria resulted in 32 RCTs studying 1354 sockets, which addressed the clinical and histologic outcomes of flapless extraction with socket grafting and provided dimensional and histologic information at or beyond the 12-week reentry period. From these RCTs, the mean loss of buccolingual width at the ridge crest was lowest for xenografts (1.3 mm), followed by allografts (1.63 mm), alloplasts (2.13 mm), and sockets without any socket grafting (2.79 mm). Only 3 studies reported on loss of width at 3 mm below the ridge crest. The mean loss of buccal wall height from the ridge crest was lowest for xenografts (0.57 mm) and allografts (0.58 mm), followed by alloplasts (0.77 mm) and sockets without any grafting (1.74 mm). The mean histologic outcomes at or beyond the 12-week reentry period revealed the highest vital bone content for sockets grafted with alloplasts (45.53%), followed by sockets with no graft material (41.07%), xenografts (35.72%), and allografts (29.93%). The amount of remnant graft material was highest for sockets grafted with allografts (21.75%), followed by xenografts (19.3%) and alloplasts (13.67%). The highest connective tissue content at the time of reentry was seen for sockets with no grafting (52.53%), followed by allografts (51.03%), xenografts (44.42%), and alloplast (38.39%). Data for new and emerging biomaterials such as cell therapy and tissue regenerative materials were not amenable to calculations because of biomaterial heterogeneity and small sample sizes.
After flapless extraction of teeth, and using a minimum healing period of 12 weeks as a temporal measure, xenografts and allografts resulted in the least loss of socket dimensions compared to alloplasts or sockets with no grafting. Histologic outcomes after a minimum of 12 weeks of healing showed that sockets grafted with alloplasts had the maximum amount of vital bone and the least amount of remnant graft material and remnant connective tissue. There is a limited but emerging body of evidence for the predictable regeneration of deficient buccal bone with socket grafting materials, need for barrier membranes, use of tissue engineering, and use of autogenous soft tissue grafts from the palate to cover the socket.
Copyright © 2015 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.
... Studies have shown that implementing socket preservation techniques can enhance prosthodontic and aesthetic outcomes when implants are used [3]. In fact, the need for hard tissue augmentation at the time of implant placement was found to be five times higher when socket or ridge preservation was not performed on the day of extraction [4,5]. ...
Background
Socket preservation is a proactive approach that limits bone loss after tooth extraction to maintain adequate bone volume, height and width. Many methods have proven effective in achieving socket preservation, including using various bone grafts and autologous platelet concentrates (APCs). Combining these two methods may lead to improved results in socket preservation and patient outcomes.
Aims
To compare the combined use of APCs and bone grafts in socket preservation, with the use of bone grafts alone. Primary outcomes were radiographic vertical bone loss (VBL) and horizontal bone loss (HBL).
Methods
A search on Pubmed, Scopus, Embase and Google Scholar databases was conducted to identify human studies using APCs in extraction sockets between January 2014 and August 2024. The inclusion criteria involved comparative human studies ranging from evidence levels II to III (Oxford Centre for Evidence-Based Medicine Levels of Evidence). For assessing bias in the included studies, the Cochrane Risk of Bias tools were used. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to determine the quality of evidence available.
Results
A total of five randomised controlled trials (RCTs) were included in the analysis. Studies included the use of platelet rich fibrin (PRF), injectable platelet rich fibrin (i-PRF), advanced platelet rich fibrin (A-PRF), advanced platelet rich fibrin plus (A-PRF+) and concentrated growth factors (CGF). The risk of bias was judged high and moderate for two out of five RCTs. The analysis revealed a combined effect size for VBL reduction, with a standardized mean difference (SMD) of −0.83 ( p < 0.001; 95% confidence interval (CI) = [−1.2, −0.57]; I² = 73.13%). For HBL reduction, the combined effect size was SMD = −0.72 ( p < 0.001; 95% CI = [−1.08, −0.37]; I² = 68.34%). The overall evidence quality rating for the use of APCs in combination with bone grafts to reduce VBL during socket preservation was assessed as moderate, whereas to reduce HBL it was determined to be low.
Conclusion
The current literature demonstrates the added benefits of APCs combined with bone grafts in alveolar socket preservation compared to bone grafts alone in reducing vertical and horizontal bone loss. However, based on the GRADE assessment, the quality of evidence was judged low-to-moderate. Further randomised clinical studies would increase the certainty of the evidence.
... The surgical approaches included flap or flapless surgery and primary or secondary wound closure. The materials included barrier membranes and/or bone grafts (Araújo and Lindhe 2009;Artzi, Tal, and Dayan 2000;Barboza et al. 2010;Barone et al. 2013Barone et al. , 2014Brownfield and Weltman 2012;Darby, Chen, and De Poi 2008;Engler-Hamm et al. 2011;Fickl et al. 2008;Iasella et al. 2003;Mardas, Chadha, and Donos 2010;Weng, Stock, and Schliephake 2011). ARP procedures have been shown to reduce, but not eliminate, the dimensional bone changes following the extraction of single-and multi-rooted teeth compared to spontaneous socket healing. ...
Objective
The aim of this study was to evaluate the effectiveness of a novel biomaterial (FG) for alveolar ridge preservation compared to CTG in terms of soft tissue thickness and bone dimensional changes.
Materials and Methods
A randomized clinical trial was conducted on 30 patients who required extraction of 30 hopeless mandibular posterior teeth. All patients went through atraumatic tooth extraction, and then, they were randomly allocated to either a CTG, an FG, or a spontaneous healing (SH) group (1:1:1). All patients received a dental implant placed 6 months postoperatively. The soft tissue thickness and bone dimensional changes were measured before and 6 months after the procedure.
Results
The study's analysis revealed statistically significant differences in buccal gingival thickness and dimensional bone changes across the three examined groups after 6 months (p < 0.05). The SH group had lower gingival thickness (1.31 ± 0.65 mm) and higher vertical resorption (−1.46 ± 1.67 mm at the buccal aspect) compared with the CTG and FG groups. The CTG and FG groups had similar gingival thickness (2.42 ± 0.70 and 3.00 ± 0.71 mm, respectively) and bone width reduction (+0.86 ± 2.31 and +0.93 ± 2.38 mm, respectively), whereas the CTG group had lower vertical bone loss (−0.30 ± 1.09 mm at the buccal aspect) than the FG group (−0.47 ± 2.30 mm at the buccal aspect).
Conclusion
FG and CTG demonstrate equivalent soft tissue thickness and comparable horizontal bone dimension outcomes in ARP.
... Parabéns a esse grupo tão querido, e vamos aproveitar o primoroso trabalho. Boa leitura!!! de próteses implanto suportadas (Seibert ad Salama, 1996 Várias técnicas de PRA podem ser utilizadas no tratamento dos alvéolos de extração, como: uso de enxertos autógenos, xenógenos e alógenos no preenchimento do alvéolo, e a técnica da regeneração óssea guiada com utilização de membranas (Weng et al., 2011;Douglass, 2005;Calasans-Maia et al., 2008). ...
Este livro tem como objetivo ser um manual prático para a reconstrução alveolar, procedimento cuja necessidade se tornou imprescindível para a clínica diária. O livro, além de pontuar os principais conhecimentos sobre o tema na literatura científica moderna, irá de forma prática mostrar o protocolo em forma de passo a passo para a execução definitiva da reconstrução alveolar proteticamente guiada. Por meio de um caso clínico, irá exemplificar todo o conteúdo, técnica e a conduta de execução, contendo imagens em alta definição.
... Guided bone regeneration immediately after tooth extraction reduces alveolar volume loss, promotes faster tissue regeneration, increases the possibility of future implant installation, and provides better aesthetic results for rehabilitation with implant-supported prostheses 19 . ...
This study was performed to evaluate the short-term preservation of alveolar bone volume with or without a polypropylene barrier and exposure of the area after extractions. Thirty posterior tooth extraction sockets were distributed randomly to a control group (n = 15; extraction and suture) and a barrier group (n = 15; extraction, barrier, and suture). All sutures and barriers were removed 10 days postoperatively. Cone beam computed tomography scans taken with the aid of a tomographic guide were obtained preoperatively, immediately postoperative, and at 120 days postoperative. A visual analysis of the coronal sections of the alveolus was performed, and vertical loss in the mesial, distal, buccal, and lingual bone ridges and horizontal thickness were evaluated. The mean vertical loss after extraction did not differ significantly between the control and barrier groups (Student t-test: mesial P = 0.989, buccal P = 0.997, lingual/palatal P = 0.070, distal P = 0.107). The mean vertical loss at 120 days postoperative did not differ significantly between the control (0.65 mm) and barrier (0.52 mm) groups (P > 0.05), with an effect size of 0.13 mm. At 120 days, the barrier group presented a mean resorption in thickness (0.45 mm) that was significantly lower than that in the control group (0.76 mm) (P = 0.021), with an effect size of 0.31 mm. The polypropylene barrier reduced the horizontal resorption in sockets of posterior teeth after extraction.
... In order to preserve the original dimensions of the alveolar bone after the dental extraction and to promote the bone regeneration of the residual alveolus, several grafts and bone substitutes are used in combination or not with membranes for guided tissue regeneration (GTR). Among these graft materials, the deproteinized bovine bone mineral (DBBM), has a biological structure similar to that of human bone, is capable of promoting bone regeneration and preserving the pre-removal dimensions of the alveolar bone when grafted on alveoli immediately after the extraction [4,[14][15]. ...
... The findings of present prospective randomized study indicate that ridge preservation using combination of collagen sponge with I-PRF with a flapless approach minimized ridge resorption in all dimensions in comparison to other findings recorded after tooth extraction without alveolar ridge preservation. Bone loss recorded at the coronal part and on the buccal aspect of the ridge are within the range of results reported in previous studies testing various alveolar ridge preservation surgical techniques and materials (11,12) . These studies and systematic reviews (13)(14)(15)(16) , point to a significant reduction, but not complete elimination, in vertical and horizontal bone resorption compared to unassisted socket healing after alveolar ridge preservation procedures. ...
... The last search was conducted on 16 April 2018. To complement the database search, cross-searching of cited references in 24 systematic reviews on the topic of ARP published until 1 May 2018 (Atieh et al., 2015;Avila-Ortiz et al., 2014;Barallat et al., 2014;Castro et al., 2017;Chan, Lin, Fu, & Wang, 2013;Corbella, Taschieri, Francetti, Weinstein, & Del Fabbro, 2017;De Risi, Clementini, Vittorini, Mannocci, & De Sanctis, 2015;Del Fabbro et al., 2017;Horvath, Mardas, Mezzomo, Needleman, & Donos, 2012;Iocca et al., 2017;Jambhekar, Kernen, & Bidra, 2015;Lee, Lee, Koo, Seol, & Lee, 2018;MacBeth et al., 2017; Vittorini Orgeas et al., 2013;Weng, Stock, & Schliephake, 2011;Willenbacher et al., 2016) was also performed. Additionally, in an attempt to identify relevant information in the grey literature, two open databases, OpenGrey (www.opengrey.eu) ...
Purpose
The aim of this systematic review was to critically analyze the available evidence on the effect of different modalities of alveolar ridge preservation (ARP) as compared to tooth extraction alone in function of relevant clinical, radiographic and patient‐centered outcomes.
Material and Methods
A comprehensive search aimed at identifying pertinent literature for the purpose of this review was conducted by two independent examiners. Only randomized clinical trials (RCTs) that met the eligibility criteria were selected. Relevant data from these RCTs were collated into evidence tables. Endpoints of interest included clinical, radiographic, and patient‐reported outcome measures (PROMs). Interventions reported in the selected studies were clustered into ARP treatment modalities. All these different ARP modalities were compared to the control therapy (i.e. spontaneous socket healing) in each individual study after a 3‐ to 6‐month healing period. Random effects meta‐analyses were conducted if at least two studies within the same ARP treatment modality reported on the same outcome of interest.
Results
A combined database, grey literature and hand search identified 3,003 records of which 1,789 were screened after removal of duplicates. Following the application of the eligibility criteria, 25 articles for a total of 22 RCTs were included in the final selection, from which 9 different ARP treatment modalities were identified: 1. Bovine bone particles (BBP) + Socket sealing (SS), 2. Construct made of 90% bovine bone granules and 10% porcine collagen (BBG/PC) + SS, 3. Cortico‐cancellous porcine bone particles (CPBP) + SS, 4. Allograft particles (AG) + SS, 5. Alloplastic material (AP) with or without SS, 6. Autologous blood‐derived products (ABDP), 7. Cell therapy (CTh), 8. Recombinant morphogenic protein‐2 (rh‐BMP2), and 9. SS alone. Quantitative analyses for different ARP modalities, all of which involved socket grafting with a bone substitute, were feasible for a subset of clinical and radiographic outcomes. The results of a pooled quantitative analysis revealed that ARP via socket grafting (ARP‐SG), as compared to tooth extraction alone, prevents horizontal (Mean = 1.99 mm; 95% CI 1.54 to 2.44; P < 0.00001), vertical mid‐buccal (Mean = 1.72 mm; 95% CI 0.96 to 2.48; P < 0.00001) and vertical mid‐lingual (Mean = 1.16 mm; 95% CI 0.81 to 1.52; P < 0.00001) bone resorption. Whether there is a superior ARP or SS approach could not be determined on the basis of the selected evidence. However, the application of particulate xenogenic or allogenic materials covered with an absorbable collagen membrane or a rapidly‐absorbable collagen sponge was associated with the most favorable outcomes in terms of horizontal ridge preservation. A specific quantitative analysis showed that sites presenting a buccal bone thickness > 1.0 mm exhibited more favorable ridge preservation outcomes (difference between ARP [AG+SS] and control = 3.2 mm), as compared to sites with a thinner buccal wall (difference between ARP [AG+SS] and control = 1.29 mm). The effect of other local and systemic factors could not be assessed as part of the quantitative analyses. PROMs were comparable between the experimental and the control group in two studies involving the use of ABDP. The effect of other ARP modalities on PROMs could not be investigated, as these outcomes were not reported in any other clinical trial included in this study.
Conclusion
ARP is an effective therapy to attenuate the dimensional reduction of the alveolar ridge that normally takes place after tooth extraction.
This article is protected by copyright. All rights reserved.
... 8e11 Notably, systemic studies of ridge preservation following tooth extraction have reported a 59% and 109% reductions of the horizontal and vertical ridge loss, respectively, after management of the tooth extraction sockets. 7 Because histological results suggest a delay in bone regeneration at the grafting sites without inflammation, the appropriateness of inserting materials into the extraction sockets has been considered questionable. It has been shown that the amount of new bone formation at the grafted sites with bovine bone mineral particles is equal to that at the ungrafted sites. ...
Background/purpose:
Extraction of the third molar may cause post-operative complications. This study assessed whether application of pure type-1 collagen to the third molar extraction socket can reduce post-operative pain score and duration and promote socket bone healing.
Methods:
Fourteen patients who underwent 20 bilateral and symmetric third molar extractions were included in this study. After two tooth extractions at two different occasions in the same patient, one socket was filled with pure type-1 collagen (experimental group, n = 20) and the other socket received nothing but the blood clot (control group, n = 20). The post-operative pain score and duration, mouth-opening limitation, and the bone density at the socket site were assessed at weeks 1, 2, 4, and 8 after tooth extraction.
Results:
Patients in the experimental group had a significantly lower mean post-operative pain score (2.6 ± 1.2) than patients in the control group (4.7 ± 2.0), and had a significantly shorter post-operative pain duration (2.7 ± 1.4 days) than patients in the control group (3.7 ± 1.8 days). We also observed a significantly lower frequency of mouth-opening limitation in 20 experimental-group patients (45%) than in 20 control-group patients (90%, P = 0.007). Moreover, a significantly higher mineralization ratio (10.2%) was found in the experimental socket site than in the control socket site.
Conclusion:
Application of pure type-1 collagen to the third molar extraction socket can reduce post-operative pain score and duration, decrease the frequency of mouth-opening limitation, and increase mineralization ratio at the extraction socket site.
... Hard-tissue preservation techniques are typically used for ankylosed teeth with a vertical soft-tissue deficiency, teeth with soft-tissue recessions and teeth with lack of keratinized tissue. The hard-tissue preservation technique employs a variety of biomaterials (59,74,138,147) but because of the 6-to 8-week healing period, only minimal new-bone formation can be expected within the extraction socket at the time of complete soft-tissue closure (86). Accordingly, the bone-substitute materials serve mainly as a space-maintaining device for the biomaterial or the soft-tissue graft. ...
Periodontal plastic surgery comprises an increasing part of clinical periodontology. Clinical trials have traditionally used professionals to judge esthetic outcome, and few studies have addressed patient needs and requests (true end points). Development of universally accepted and validated methods for professional esthetic assessment, together with standardized questionnaires for patient-perceived outcome, may help to provide better insights into the true needs and benefits of periodontal and implant-associated plastic surgery. In this volume of Periodontology 2000, experienced researchers and clinicians from different subdisciplines of periodontology evaluate: treatment of gingival recession with or without papilla elevation; clinical crown lengthening in the natural dentition and in prosthodontic preparative treatment; periodontal regeneration around natural teeth; and soft-tissue augmentation in edentulous areas. Similarly, experts in different areas of implant science address esthetic outcomes with single and multiple implant rehabilitation, alveolar ridge preservation, implant positioning and immediate implant placement in the esthetic zone.
... When materials (e.g. occlusive membranes and/or bone grafts) (Araujo & Lindhe, 2009b;Artzi, Tal, & Dayan, 2000;Barboza, Stutz, Ferreira, & Carvalho, 2010;Barone, Ricci, Tonelli, Santini, & Covani, 2013;Barone et al., 2014;Brownfield & Weltman, 2012;Darby, Chen, & De Poi, 2008;Engler-Hamm, Cheung, Yen, Stark, & Griffin, 2011;Fickl, Zuhr, Wachtel, Stappert et al., 2008;Iasella et al., 2003;Lekovic et al., 1998;Mardas, Chadha, & Donos, 2010;Weng et al., 2011). These studies and systematic reviews (Esposito et al., 2009;Hammerle et al., 2012;Ten Heggeler et al., 2011;Vignoletti et al., 2012;Wang & Lang, 2012;Willenbacher, Al-Nawas, Berres, Kammerer, & Schiegnitz, 2015) point to a significant reduction, but not complete elimination, in vertical and horizontal bone resorption compared to unassisted socket healing after ARP procedures. ...
Aim:
To test whether the use of collagen matrix seal (CMS) results in similar hard and soft tissue remodeling to that with collagen sponge (CS) used as barriers 4 months following alveolar ridge preservation (ARP), in combination with freeze-dried bone allograft (FDBA).
Materials and methods:
Twenty-eight patients were randomly assigned to the two groups. Clinical and radiographic measurements were recorded with the same stent at baseline and 4 months for standardization. The flapless technique following atraumatic extraction was used for the two types of barriers.
Results:
All patients completed the study, 14 in the CMS group and 14 in the CS group. Reduction in coronal ridge width (1.21 mm-14.91%CMS and 1.47 mm-20.40% CS)and vertical buccal bone resorption (0.30 mm CMS and 0.79 mm CS) were not significantly different. A slight increase in buccal gingival thickness at the coronal part was observed in both groups (0.9 mm CMS and 0.5 mm CS).
Conclusions:
CMS and CS, when combined with FDBA, significantly minimized ridge resorption in all dimensions and maintained buccal soft tissue thickness in sockets with a buccal plate loss of <2 mm in comparison to previously reported findings recorded after tooth extraction without ARP. ClinicalTrials. gov (NCT02697890). This article is protected by copyright. All rights reserved.
... La résorption est également plus faible en absence de lambeau car le périoste amène la vascularisation nécessaire à la cicatrisation [8,9]. D'après Weng D et al., les méthodes de préservation de crête permettraient de diminuer la lyse osseuse alvéolaire significativement dans le sens horizontal et dans le sens vertical [10]. Cependant, aucun des matériaux de greffe utilisés actuellement ne permettent de préserver complètement le volume osseux après une extraction dentaire et il n'existe pas de consensus ni de recommandations pour utiliser une technique ou un matériau particulier [8,11]. ...
... Various evidence has proved that the bone loss occurs after extraction and more at the labial side of the alveolar process compared to the lingual or the palatal side. [1] A clinical study on 46 patients evaluated bone healing and soft tissue contour changes after tooth removal. They found an approximate 50% reduction in the buccolingual width of edentulous sites after 12 months. ...
Aims:
To investigate clinically and radiographically, the bone fill in extraction sockets using demineralized freeze-dried bone allograft alone and along with platelet-rich fibrin (PRF).
Materials and methods:
A randomized controlled clinical trial was carried out on 36 nonrestorable single-rooted teeth sites. Sites were randomized into demineralized freeze-dried bone allograft (DFDBA) combined with PRF - test and DFDBA - control groups using a coin toss method. After the placement of graft material, collagen membrane was used to cover it. The clinical parameters recorded were ridge width and ridge height. All the parameters were recorded at baseline and at 90 and 180 days.
Statistical analysis used:
Independent t-test and paired t-test.
Results:
In both groups, there is significant reduction in loss of ridge width and ridge height from baseline to 90 days (P < 0.001), baseline to 180 days (P < 0.001), and 90-180 days (P < 0.001). However, when both the groups were compared the test group favored in the reduction of ridge width while there was no statistical difference in reduction of ridge height among at different intervals.
Conclusions:
Although DFDBA is considered as an ideal graft material, PRF can be used as an adjunctive with DFDBA for socket preservation.
... Horizontal bone loss at the coronal part of the ridge (1.6 to 2.0 mm, 19.1% to 24.4%) and vertical bone loss on the buccal aspect (0.7 to 1.0 mm) are within the range of findings from previous studies using different bone grafts and membranes for ARP. [5][6][7][8][9][10][11][12][13][14][15][16][17][18] These studies as well as systematic reviews [1][2][3][4]43 indicate that vertical and horizontal bone resorption is significantly reduced but not totally eliminated in comparison to unassisted socket healing after ARP procedures. 43 A recent meta-analysis showed a mean difference between ARP and unassisted socket healing of approximately 1.31 to 1.54 mm in bucco-oral bone width and 0.91 to 1.12 mm in bone height, and it further showed that implants could be inserted into the determined position without further augmentation in 90.1% of ARP sites, whereas this was the case in only 79.2% of sites in unassisted healing. ...
Background:
Extractions are followed by significant dimensional changes in the alveolar crest that may preclude implant placement. The purpose of this randomized controlled prospective study was to compare the preservation of soft and hard tissues dimensional changes following alveolar ridge preservation (ARP) using two membranes consisting of collagen matrix (CM) or extracellular matrix (ECM) as barriers over FDBA.
Methods:
Standardized clinical and radiographic measurements of soft and hard tissues were recorded by means of a stent before and 4 months after the ARP. The surgery entailed sulcular incisions with minimal flap elevation and repositioning without advancement.
Results:
Among eleven patients in the CM and twelve in the ECM groups who completed the study, gingival thickness increased 0.1 to 0.2 mm for both groups along with a decrease in the width of keratinized tissue of 0.5 mm following healing. Reductions in the ridge width were most pronounced at the coronal aspect, 1.8 mm for CM and 2.0 mm for ECM, whereas vertical reduction was most pronounced on the buccal aspect, 0.7 to 1.0 mm. These differences between groups were not statistically significant. However, significant correlations for changes in gingival thickness (p=0.001) and crestal bone width (p=0.002) with pre-operative buccal plate thickness were observed.
Conclusions:
Both xenogeneic collagen matrices combined with FDBA were effective in maintaining soft tissues and minimizing ridge resorption in all dimensions following ARP. The buccal plate thickness was an important determinant for the amount of change in crestal gingival thickness and ridge width.
... Thus, it seems prudent to try to prevent alveolar ridge resorption in order to preserve the alveolar ridge at tooth extraction. Preservation of postextraction sockets seems to be effective in reducing ridge resorption after tooth extraction [9][10][11] . Nevertheless, no recommendations for a specific technique or material can be made yet, as a consequence, further studies are needed to clarify these issues. ...
To compare epithelial connective tissue graft vs porcine collagen matrix for sealing postextraction sockets grafted with deproteinised bovine bone.
A total of 30 patients, who needed a maxillary tooth to be extracted between their premolars and required a delayed, fixed, single implant-supported restoration, had their teeth atraumatically extracted and their sockets grafted with deproteinised bovine bone. Patients were randomised according to a parallel group design into two arms: socket sealing with epithelial connective tissue graft (group A) vs porcine collagen matrix (group B). Outcome measures were: implant success and survival rate, complications, horizontal and vertical alveolar bone dimensional changes measured on Cone Beam computed tomography (CBCT) scans at three levels localised 1, 3, and 5 mm below the most coronal aspect of the bone crest (levels A, B, and C); and between the palatal and buccal wall peaks (level D); and peri-implant marginal bone level changes measured on periapical radiographs.
15 patients were randomised to group A and 15 to group B. No patients dropped out. No failed implants or complications were reported 1 year after implant placement. Five months after tooth extraction there were no statistically significant differences between the 2 groups for both horizontal and vertical alveolar bone dimensional changes. At level A the difference was 0.13 ± 0.18; 95% CI 0.04 to 0.26 mm (P = 0.34), at level B it was 0.08 ± 0.23; 95% CI -0.14 to 0.14 (P = 0.61), at level C it was 0.05 ± 0.25; 95% CI -0.01 to 0.31 mm (P = 0.55) and at level D it was 0.13 ± 0.27; 95% CI -0.02 to 0.32 mm (P = 0.67). One year after implant placement there were no statistically significant differences between the 2 groups for peri-implant marginal bone level changes (difference: 0.07 ± 0.11 mm; 95% CI -0.02 to 0.16; P = 0.41).
When teeth extractions were performed atraumatically and sockets were filled with deproteinised bovine bone, sealing the socket with a porcine collagen matrix or a epithelial connective tissue graft showed similar outcomes. The use of porcine collagen matrix allowed simplification of treatment because no palatal donor site was involved.
... Several studies have been conducted to evaluate the effectiveness of different ARP surgical techniques (e.g., flapped versus flapless and primary intention healing versus no primary closure) and materials (e.g., occlusive membranes and bone grafts), and several approaches have proven successful to varying degrees [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]. Systematic reviews indicate that the combination of bone grafts with resorbable membranes achieved the best results [1][2][3]. ...
Alveolar ridge preservation (ARP) has been shown to prevent postextraction bone loss. The aim of this report is to highlight the clinical, radiographic, and histological outcomes following use of a bilayer xenogeneic collagen matrix (XCM) in combination with freeze-dried bone allograft (FDBA) for ARP. Nine patients were treated after extraction of 18 teeth. Following minimal flap elevation and atraumatic extraction, sockets were filled with FDBA. The XCM was adapted to cover the defect and 2-3 mm of adjacent bone and flaps were repositioned. Healing was uneventful in all cases, the XCM remained in place, and any matrix exposure was devoid of further complications. Exposed matrix portions were slowly vascularized and replaced by mature keratinized tissue within 2-3 months. Radiographic and clinical assessment indicated adequate volume of bone for implant placement, with all planned implants placed in acceptable positions. When fixed partial dentures were placed, restorations fulfilled aesthetic demands without requiring further augmentation procedures. Histological and immunohistochemical analysis from 9 sites (4 patients) indicated normal mucosa with complete incorporation of the matrix and absence of inflammatory response. The XCM + FDBA combination resulted in minimal complications and desirable soft and hard tissue therapeutic outcomes, suggesting the feasibility of this approach for ARP.
... Various ridge preservation techniques have been proposed. Some have been demonstrated to significantly maintain more ridge width and height compared to the healing by a blood clot alone (55,72,73,108,121,125). More recent evidence suggest that more stable soft tissue dimensions can be obtained at 6-8 weeks post extraction by applying a slowly resorbable biomaterial within the extraction socket and covering it with an autogenous soft tissue punch from the palate (Fig. 1) (62). ...
Dental implants have proven to be a successful treatment option in fully and partially edentulous patients, rendering long-term functional and esthetic outcomes. Various factors are crucial for predictable long-term peri-implant tissue stability, including the biologic width; the papilla height and the mucosal soft-tissue level; the amounts of soft-tissue volume and keratinized tissue; and the biotype of the mucosa. The biotype of the mucosa is congenitally set, whereas many other parameters can, to some extent, be influenced by the treatment itself. Clinically, the choice of the dental implant and the position in a vertical and horizontal direction can substantially influence the establishment of the biologic width and subsequently the location of the buccal mucosa and the papilla height. Current treatment concepts predominantly focus on providing optimized peri-implant soft-tissue conditions before the start of the prosthetic phase and insertion of the final reconstruction. These include refined surgical techniques and the use of materials from autogenous and xenogenic origins to augment soft-tissue volume and keratinized tissue around dental implants, thereby mimicking the appearance of natural teeth.
... Surprisingly, many of them do not report on clinically relevant outcomes, such as linear or volumetric changes, and only a few include an adequate control (i.e., undisturbed alveolus). These shortcomings are also reflected in the systematic reviews (Ten Heggeler et al., 2011;Weng et al., 2011;Horvath et al., 2012;Morjaria et al., 2014) and meta-analyses available on the topic (Vignoletti et al., 2012;Vittorini Orgeas et al., 2013), which present a major limitation: pooling of data from studies with marked methodological and clinical heterogeneity (e.g., single-and multirooted teeth). This raises concerns about the possibility of generating inconsistent conclusions that over-or underestimated the therapeutic potential of specific ridge preservation strategies (De Buitrago et al., 2013). ...
Alveolar ridge preservation strategies are indicated to minimize the loss of ridge volume that typically follows tooth extraction. The aim of this systematic review was to determine the effect that socket filling with a bone grafting material has on the prevention of postextraction alveolar ridge volume loss as compared with tooth extraction alone in nonmolar teeth. Five electronic databases were searched to identify randomized clinical trials that fulfilled the eligibility criteria. Literature screening and article selection were conducted by 3 independent reviewers, while data extraction was performed by 2 independent reviewers. Outcome measures were mean horizontal ridge changes (buccolingual) and vertical ridge changes (midbuccal, midlingual, mesial, and distal). The influence of several variables of interest (i.e., flap elevation, membrane usage, and type of bone substitute employed) on the outcomes of ridge preservation therapy was explored via subgroup analyses. We found that alveolar ridge preservation is effective in limiting physiologic ridge reduction as compared with tooth extraction alone. The clinical magnitude of the effect was 1.89 mm (95% confidence interval [CI]: 1.41, 2.36; p < .001) in terms of buccolingual width, 2.07 mm (95% CI: 1.03, 3.12; p < .001) for midbuccal height, 1.18 mm (95% CI: 0.17, 2.19; p = .022) for midlingual height, 0.48 mm (95% CI: 0.18, 0.79; p = .002) for mesial height, and 0.24 mm (95% CI: -0.05, 0.53; p = .102) for distal height changes. Subgroup analyses revealed that flap elevation, the usage of a membrane, and the application of a xenograft or an allograft are associated with superior outcomes, particularly on midbuccal and midlingual height preservation.
... A comprehensive review of the effect of socket grafting on alveolar dimension changes found a horizontal preservation of 59% and a vertical preservation of 109%. 10 No consensus has been reached regarding the superiority of any one specific graft material for socket preservation. 11 One commercial brand of graft material with evidence-based data on various regenerative applications is Bio-Oss (Geistlich), a bovinederived hydroxyapatite xenograft that is biocompatible, osteoconductive, and integrates with the surrounding bone on a long-term basis. ...
The aim of this prospective, randomized, controlled, multicenter study was to evaluate and compare the histologic and histomorphometric aspects of extraction sockets grafted with two commercially available bovine bone xenografts: Endobon (test group) and Bio-Oss (control group). The study was designed to ensure that baseline variables between groups were as similar as possible to allow for a direct comparison of graft healing characteristics. Thirty-eight patients contributed 62 augmented extraction sites to the study. All sites were grafted with one type of bovine bone mineral and covered with a resorbable collagen membrane for 6 months of healing prior to implant placement surgery. The histologic outcomes between the two treatment groups are similar, with de novo bone (mean ± SD) for the test group at 28.5% ± 20% and for the control group, 31.4% ± 18%. Histologic specimens also include membrane remnants. All but two implants integrated successfully after 1 year of follow-up. This investigation provides support for the efficacy of bovine bone xenograft for socket preservation when subsequent implant placement is planned.
Objective:
Fixed dental prostheses are a predictable treatment option to replace missing teeth. A periodontal-prosthodontic approach to rehabilitating those areas ensures a predictable way to achieve the desired esthetic and functional results. This is especially important in cases with high esthetic demand. An ideal esthetic result can be achieved by soft tissue overcorrection through periodontal procedures, which reduce the number of conditioning appointments of the pontic sites. Many pontic designs have been described to enhance the appearance of the restored sites. The flat (F) and step (S) pontic designs are a modification of classic pontic approaches. These designs contact the mucosa in a wide area of a previously reconstructed ridge without exerting excessive pressure, reducing the possibility of inflammation, ulceration, and facilitating cleaning. This periodontal-prosthodontic procedure aims to achieve functional and esthetic prosthodontic results in a predictable manner.
Clinical considerations:
Understanding which pontic design is recommended in different clinical situations is key for a successful outcome. The F and S pontic designs are recommended to be used in a ridge with optimal soft tissue volume after periodontal reconstruction. The suggested designs provide the clinician with a solution to different clinical scenarios after the periodontal augmentation of the pontic site has been done.
Conclusions:
The presented pontic designs are indicated in ridges where a previous soft tissue preservation or reconstruction procedure has been done to achieve an optimal soft tissue volume. Modifications to the designs can be done in the interim stage which is later replicated into the final restoration.
Clinical significance:
The combination of periodontal and prosthodontic techniques help to predictably achieve a natural looking pontic emergence profile.
With the demand for tooth/gum aesthetics in implant-supported rehabilitations, the surgeon, whether an implant specialist or not, increasingly needs to be mindful of proper care for socket preservation following extraction. The paper presented here reports the case of a male patient who manifested dental impairment of the Upper Left First Molar (tooth #26) [in FDI notation]; following tomographic analysis and after reaching a consensus with the patient, the decision was made to extract said tooth and preserve the socket for subsequent implant placement. The aim of the case report is to present a clinical case of alveolar ridge preservation through the “Double Layer Socket Preservation” technique, a technique created by Barry Barthee, whereby a xenogenous graft under an xenogenous type III collagen membrane was combined with a polypropylene barrier. Following research and study results on the subject, it was concluded that by applying this technique, the alveolar ridge is greatly preserved and bone volume is maintained, both of which are very important factors for good health of the tissues surrounding the implant and consequent increase in the survival of the implant itself.
Objectives
The aim of this study was to assess whether alveolar ridge preservation (ARP) can reduce the need of ridge augmentation at posterior tooth sites.
Material and methods
This study enrolled patients who received dental implants at posterior tooth sites during 2013–2019. Demographic data and dental treatment histories were collected. Based on healing patterns after tooth extraction, patients were divided into ARP and spontaneous healing (SH) groups. Three surgical treatment plans were devised according to the alveolar bone volume on cone-beam computed tomography (CBCT). The three treatment plans were to perform implant alone, simultaneous guided bone regeneration (GBR) and implantation, and staged GBR before implantation. Statistical analyses were performed to determine relationships.
Results
There were 92 implant records in the ARP group and 249 implant records in the SH group. A significant intergroup difference was observed regarding the frequency distribution of the treatment modality of staged GBR before implant (χ² = 15.07, p = 0.0005). Based on the implant alone treatment modality and simple logistic regression, the SH pattern was related to staged GBR before implant (SH vs. ARP: crude odds ratio (OR) = 4.65, 95% confidence interval (CI) = 2.15–11.61, p = 0.0003). After adjusting confounding factors, the risk was still significant (adjusted OR = 5.02, 95% CI = 2.26–12.85, p = 0.0002).
Conclusions
The study results suggested that ARP is more likely to lead to the treatment modality of implant alone and reduce the need for staged GBR before implantation.
Clinical relevance
This study describes ARP capable of minimizing the need for staged GBR before implantation and shortening the treatment duration.
In the dental implant era, there has been growing interest in exploring the most effective methods to minimize morphologic alteration in the postextraction site. Despite modern methods of ridge preservation, resorption of the ridge is inevitable. The optimal approach to minimizing the rate and amount of these changes is still a subject of controversy. This article provides a contemporary review of the different approaches to preserve alveolar ridge dimensions. A suggested classification for single extraction sockets is presented along with multiple treatment options for each class.
In the esthetic zone, in the case of tooth extraction, the clinician is often confronted with a challenge regarding the optimal decision-making process for providing a solution using dental implants. This is because, after tooth extraction, alveolar bone loss and structural and compositional changes of the covering soft tissues, as well as morphological alterations, can be expected. Ideally, the therapeutic plan starts before tooth extraction and it offers three options: spontaneous healing of the extraction socket; immediate implant placement; and techniques for preserving the alveolar ridge at the site of tooth removal. The decision-making process mainly depends on: (i) the chosen time-point for implant placement and the ability to place a dental implant; (ii) the quality and quantity of soft tissue in the region of the extraction socket; (iii) the remaining height of the buccal bone plate; and (iv) the expected rates of implant survival and success. Based on scientific evidence, three time-periods for alveolar ridge preservation are described in the literature: (i) soft-tissue preservation with 6–8 weeks of healing after tooth extraction (for optimization of the soft tissues); (ii) hard- and soft-tissue preservation with 4–6 months of healing after tooth extraction (for optimization of the hard and soft tissues); and (iii) hard-tissue preservation with > 6 months of healing after tooth extraction (for optimization of the hard tissues).
The rehabilitation of partially or totally edentulous patients with implant-supported prostheses has become routine, with excellent long-term outcome. A proper implant position is mandatory to achieve good functional and esthetic outcome and may require an adequate amount of alveolar bone and surrounding soft tissue. When this is lacking because of atrophy, sequelae of periodontal disease, traumas or congenital malformations, increased bone volume and/or keratinized mucosa can be obtained by guided bone regeneration, bone-grafting techniques and alveolar bone expansion. This article presents an evidence-based, prosthetically driven approach for the treatment of edentulous ridges with horizontal defects. The classification of bony defects, the main augmentation techniques, the selection criteria among different surgical procedures for different types of bony defects, and the advantages, disadvantages and limitations of each technique, are described in detail.
Objectives:
To evaluate the changes in marginal bone levels (MBL) and soft tissue dimension around platform-switched implants with the implant-abutment junction (IAJ) placed at the crest or 1.5-2 mm subcrestally.
Materials and methods:
In all, 96 platform-switched implants were placed in either the posterior maxilla or mandible in 48 partially edentulous patients in a split-mouth study. All implants were provisionally restored after 4-5 months and definitively after 6 months (T6). Radiographic assessment of MBL was assessed at implant placement (T0), T6, 12 months (T12), and 18 months (T18) after placement. Mid-buccal soft tissue and papilla measurements were performed at T6, T12, and T18.
Results:
In all, 43 patients with 86 implants completed the study. The T18 examination showed an implant survival rate of 100% in both groups. Analysis showed that MBL varied as a function of IAJ location, which indicated more coronal bone levels with subcrestal (2.39 ± 0.08 mm) than with epicrestal placements (0.88 ± 0.08 mm) (p < .05). Greater average marginal bone loss was found in the subcrestal group (0.40 ± 0.07 mm) compared to the epicrestal group (0.13 ± 0.08 mm) although no statistically significant difference was found at T18 (p > .05). Levels of mid-buccal soft tissue had no significant changes over time, regardless of group (p > .05). There was a significant difference in increase in papilla between T6 and T12 and T18 (p = .005 and .001), but not between T12 and T18 (p = .61). These papilla levels and changes were similar between groups (p > .05).
Conclusions:
The MBL changes around platform-switched implants with same geometry were not affected by the epicrestal or subcrestal location of the IAJ. Furthermore, the location of the IAJ did not affect the implant survival and soft tissue dimensions. However, no bone loss was located apical to the IAJ when the implants were placed subcrestally.
A successful implant treatment presupposes an effective osseointegration, which is the direct apposition of bone to the implant surface. The implant surface plays a huge role in the bone response leading to osseointegration. For this reason, evaluation of chemical and physical characteristics is considered important in order to choose the best implant and obtain optimal clinical results. Although it is not clear which specific surface confers a true advantage, there is a general consensus that a roughened surface gives better results compared to machined one.
Bone remodeling after extraction may have an influence on the implant treatment planning and clinical results. Finally, optimal osseointegration mechanisms, good primary stability, and high bone-to-implant contact (BIC) should guarantee the best results at long term.
A relatively recent technology, the piezoelectric surgery, which has the best cutting efficiency on mineralized tissue without overheating the bone, may contribute to reduce the bone trauma before implant placement. Also, it can aid in inserting the implants in difficult clinical situations like the contiguity to delicate structures such as the inferior alveolar nerve or the maxillary sinus.
The aim of this overview was to evaluate and compare the quality of systematic reviews, with or without meta-analysis, that have evaluated studies on techniques or biomaterials used for the preservation of alveolar sockets post tooth extraction in humans. An electronic search was conducted without date restrictions using the Medline/PubMed, Cochrane Library, and Web of Science databases up to April 2015. Eligibility criteria included systematic reviews, with or without meta-analysis, focused on the preservation of post-extraction alveolar sockets in humans. Two independent authors assessed the quality of the included reviews using AMSTAR and the checklist proposed by Glenny et al. in 2003. After the selection process, 12 systematic reviews were included. None of these reviews obtained the maximum score using the quality assessment tools implemented, and the results of the analyses were highly variable. A significant statistical correlation was observed between the scores of the two checklists. A wide structural and methodological variability was observed between the systematic reviews published on the preservation of alveolar sockets post tooth extraction. None of the reviews evaluated obtained the maximum score using the two quality assessment tools implemented.
Tooth extraction is one of the most common procedures in oral surgery. According to the statistics of statutory German health insurances, almost 13 million teeth were extracted in Germany in 2012. Resorption of hard and soft tissue is a physiologic process that takes place after tooth extraction. Maintaining these tissues after tooth extraction can facilitate the initial situation for prosthetic restorations. Lately, socket preservation has been described as the therapy of choice for managing this issue. When is socket preservation advisable and under which conditions is caution recommended? This article provides an overview of the current literature and state of knowledge and describes advantages as well as disadvantages of this procedure.
Introduction: After tooth loss, bone-volume and soft-tissue resorption usually occur. The goal of alveolar healing is the maintenance of hard and soft tissues. Bone resorption can be reduced by hard tissue augmentation. In combination with alveolar socket seal, the ridge preservation technique supports bone regeneration. The combined epithelial subepithelial connective tissue graft is less invasive than raising a flap, and it stabilizes the soft tissue. The superstructure's emergence profile shapes the peri-implant soft tissue and determines the architecture of the red-white esthetics at the delicate transition to the implant crown. Clinical case: After implant surgery in region 12, impaired wound healing occurred, necessitating construction of a new buccal flap and re-augmentation 2 weeks after implantation at a different clinic. Augmentation led to inflammation with wound dehiscence, which impaired ossification. Therapy consisted in removal of the implant and secondary wound closure using a gingival graft and the tunnel technique. An additional hard tissue augmentation to substitute the lost bone offered a dubious prognosis. The defect in region 12 was finally closed using a single-winged resin bonded bridge. Results: The survival probability of implants has reached a high level. If performed simultaneously with tooth extraction, ridge preservation and socket seal counteract bone and soft tissue resorption. However, augmentation and tissue grafts do not eliminate the risk of bone resorption if triggered by peri-implantitis. Conclusion: Failures occur when the conditions required for conserving the alveoli, bone structure and soft tissues are not met. The prerequisites for a successful implant therapy are sufficiently thick lamellar bone, keratinized gingivae and wellreconstructed hard and soft tissues.
Background: bone continuity defects following tumour ablation, or as a result of other causes, may lead to a serious problems. The osseous free flap has become the gold standard for reconstructing these defects. Implant-supported prosthetic rehabilitation is feasible although it still represents a major challenge
Aim: the aim of this prospective clinical study is to assess the 2-year outcomes of implant-supported restorations performed using a computer-assisted template-guided flapless surgery approach in patients reconstructed with fibula or iliac crest free flaps.
Materials and Methods: twelve jaws in 10 patients were reconstructed with a fibula or iliac crest free flap after tumour resection or gunshot wound. Six to eight month later, computer-assisted template-based flapless implant placement, based on accurate prosthetic and aesthetic analysis, was performed using a customized NobelGuide protocol. Treatment success was evaluated using the following parameters: survival of implants/prostheses, prosthetic and biologic complications, marginal bone level changes, soft tissue parameters and patient satisfaction.
Results: A total of 56 Nobel Replace Tapered Groovy implants were placed; the implants ranged between 8 and 16 mm in length and were either 3.5, 4.3 or 5 mm wide. All the patients have reached the 4-year follow-up. Three implants were lost accounting for an overall implant survival rate of 94.6%. No prosthesis were lost. Some prosthetic and biologic complications were recorded. Four years after loading the mean marginal bone loss was 1.43±0.49 mm at the palatal/lingual site and 1.48±0.46 mm at the vestibular site. All the patients showed healthy soft tissues with stable probing depth (4 .93±0.75%) and successful bleeding on probing values (12±5.8%). 90% of patients were satisfied of the treatment at the 4-year follow-up.
Conclusions and clinical implications: Computer-assisted template-guided flapless implant surgery seems to be a viable option for patients undergoing reconstruction with free flaps after tumour resection or gunshot trauma, although many anatomical and prosthetic challenges remain. A high degree of patient satisfactorily was reported.
The aim of this article was to analyze the horizontal, vertical, and histological effects of alveolar ridge preservation (ARP) versus the ones of unassisted socket healing, in the format of an up-to-date review and meta-analysis.
An extensive electronic search in the electronic databases of the National Library of Medicine was conducted for articles published up to June 2014 to identify literature presenting data on the topic of ARP. Only randomized controlled trials, controlled clinical trials, and prospective trials were included for meta-analysis.
After screening 903 abstracts from the electronic database, we included 64 studies in qualitative and 18 in quantitative synthesis. Quality assessment characterized a medium risk of bias for the included literature. The meta-analysis showed a mean difference between test and control groups of approximately 1.31 to 1.54 mm in bucco-oral bone width and 0.91 to 1.12 mm in bone height. Additionally, the intergroup difference in percentage of vital bone was assessed to be inconclusive across the included studies. Implants could be inserted into the determined position without further augmentation in 90.1% of the experimental sites, while this was the case in only 79.2% of the control sockets.
Resorption of the alveolar ridge cannot be totally stopped by ARP, while it still can be prevented compared with unassisted healing. No reliable predictions on the histological effects could be made due to limited data. Further on, no recommendation for a specific technique of ARP could be made. In conclusion, there is still need for ongoing research on the topic, even though the lower percentage of implant sites that needed additional augmentation in test sockets seemed to bring a patient benefit.
© 2015 Wiley Periodicals, Inc.
This study aimed to determine healing patterns in periimplant gap defect grafted with demineralized bovine bone mineral (DBBM) and porous titanium granules (PTG), which are known to induce a minimal tissue reaction and to undergo minimal biodegradation in healing process. Experiments were performed using a standardized periimplant gap-defect model in dogs with two observational periods: 4 and 8 weeks. Circumferential defects were surgically induced around dental implants on unilateral mandibles in five dogs, and collagen barrier membranes were placed over the DBBM and PTG grafts at two experimental sites and over a nongrafted site. Four weeks later, the same procedures were performed on the contralateral mandible, and the animals allowed to heal for a further 4 weeks, after which they were sacrificed and their mandibles with graft/control sites harvested for histologic evaluation. Both types of grafted biomaterials significantly enhanced the defect fill with newly formed bone, but the bone-to-implant contact (BIC) was significantly increased only at sites that had been grafted with DBBM. The two experimental sites exhibited different healing patterns, with new bone formation being observed on the surface of the DBBM particles throughout the defect, while there was no de novo bone formation on the PTG surface, but rather appositional bone growth from the base and lateral walls of the defect. It has been suggested that gap-defect filling with DBBM around dental implants may enhance both BIC and defect fill; however, the present findings show that defect grafting with PTG enhances only defect fill and not BIC. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2015.
© 2015 Wiley Periodicals, Inc.
Aim:
To evaluate the 1-year outcome of Minimally Invasive Single Implant Treatment (M.I.S.I.T.) based on ridge preservation and contour augmentation in patients with a high aesthetic risk profile.
Materials and methods:
Periodontally healthy non-smoking patients with a failing tooth in the anterior maxilla (15-25) were selected. All were in need of a single implant and demonstrated high risk for aesthetic complications given mid-facial recession at the failing tooth and/or a buccal bone dehiscence and/or a thin-scalloped gingival biotype. Patients without mid-facial recession (NRG) received flapless tooth extraction and ridge preservation using a collagen-enriched bovine-derived xenograft, flapless installation of a bone condensing implant with variable-thread design (4-6 months later), a provisional screw-retained crown and connective tissue graft (CTG) inserted in the buccal mucosa (3 months later) and a permanent crown (3 months later). Patients with mid-facial recession (RG) were treated similarly, yet they received a CTG at the time of ridge preservation. All patients were treated by an experienced periodontist using a microsurgical approach. Primary outcome variables included papillary and mid-facial recession. Clinical parameters, pink (PES) and white aesthetic score (WES) were considered secondary outcome variables.
Results:
Fifty patients (25 females, 25 males; mean age 39, range 19-81; 42 in NRG and 8 in RG) met the selection criteria and consented to the treatment. Forty-seven could be examined at 12 months and all implants survived. Mean bone loss amounted to 0.48 mm (range 0.00-1.80) at 12 months. Papillary recession was minimal in both groups at 12 months (mean ≤ 0.3 mm), as was mid-facial recession in the NRG (mean 0.1 mm). Twelve patients in the NRG even demonstrated coronal migration of the mucosal margin following CTG and needed adaptation of the provisional crown to induce soft tissue retraction. Due to CTG at the time of ridge preservation in the RG, mid-facial soft tissue gain amounted to 0.9 mm at 12 months, hereby eliminating 2/3rd of the initial recession. PES and WES were favourable pointing to 10.9/14 and 8.2/10 respectively.
Conclusion:
This short-term prospective study offers a proof of principle of M.I.S.I.T. in patients with a high aesthetic risk profile.
Purpose(1) To clinically evaluate horizontal remodeling of the alveolar process (hard and soft tissues) following ridge preservation in high-risk patients and (2) to identify predictors of such remodeling.Materials and Methods
Periodontally healthy nonsmoking patients with a failing tooth in the anterior maxilla (15–25) were selected for a prospective case series. All were in need of a single implant and demonstrated high risk for aesthetic complications given an incomplete buccal bone wall and/or thin-scalloped gingival biotype. Following flapless tooth extraction, ridge preservation was performed using one or more collagen-enriched, bovine-derived block grafts (Geistlich Bio-Oss® Collagen® 100 mg, Geistlich Pharma AG, Wolhusen, Switzerland) without the additional use of membranes or soft tissue grafts. The change in buccopalatal dimension of the alveolar process between baseline (prior to tooth extraction) and 4 months was assessed on the basis of superimposed occlusal slides. Regression analysis was performed to identify predictors of alveolar process remodeling.ResultsForty-two patients (21 females, 21 males; mean age 38) met the selection criteria and consented to the treatment. Mean alveolar process remodeling was 14% (SD 7, range 4–30) with minimal remodeling (≤10%) in 16 patients (38%) and advanced remodeling (>20%) in 10 patients (24%). A single implant could be installed in all subjects without additional guided bone regeneration. Connective tissue grafting was performed later on in the treatment for aesthetic purposes, hereby compensating for tissue loss at the buccal aspect. Predictors of alveolar process remodeling were tooth location (central incisors and cuspids > laterals incisors and premolars), tooth abscess (p = .025), and buccal bone loss (p = .035).Conclusion
Alveolar process remodeling seems inevitable yet acceptable following ridge preservation in high-risk patients. Proper case selection may reduce the incidence of advanced remodeling.
The authors conducted a study to assess the quality of systematic reviews (SRs) published on the topic of alveolar ridge preservation (ARP).
The authors conducted a search for SRs on ARP on the basis of a set of eligibility criteria (only SRs involving ARP, with or without meta-analyses, written in English). The authors assessed the quality of the SRs independently of one another by using two established checklists.
The authors selected eight SRs. The results of all of the SRs indicated that ARP was effective in preserving the ridge volume as compared with extraction alone, but it did not fully prevent bone-resorptive events. None of the SRs, however, received the highest possible score in either of the checklists. One SR that had a score of 5 (of a possible 11) using one checklist and 5 (of a possible 14) using the other checklist had the lowest overall score. The results of this assessment revealed that a significant proportion of the investigators in the SRs did not include non-English language articles, perform hand searching of published literature or evaluate the gray literature. Assessment of publication bias and reporting of conflicts of interest also was lacking in some studies. Practical Implications. Although ARP appears to be an effective approach to preventing resorption after tooth extraction, significant structural and methodological variability exists among SRs on this topic. Future SRs on ARP should consider the use of quality assessment checklists to minimize methodological shortcomings for better dissemination of scientific evidence.
To examine bone formation in dehiscence defects using biphasic hydroxyapatite/β-tricalcium phosphate plus biphasic calcium sulfate (BCP/BCS).
After extractions, 24 mandibular buccal dehiscence defects (3 × 3 mm) were treated with BCP/BCS (E), membrane (MC), or control (NC). Histology and histomorphometric analysis were performed.
After 6 weeks, bone formation was noticeable in most sites. In subsequent phases, the woven bone was gradually remodeled into lamellar bone and marrow. Vertical new bone height in the E and MC groups (1.06 and 0.85 mm.) was substantially greater than that in the NC group (-0.28 mm). For all groups, there was an overall increase in the height of the newly formed bone through the observation. At week 12, the vertical bone height was 1.95, 2.07, and 0.29 mm, respectively. The mean new bone area in the E and MC groups was much greater than that in the NC group (2.85, 2.80, and -0.20 mm, respectively). Percent new bone in all 3 groups was similar (36.25%, 34.84%, and 28.34%, respectively).
This study demonstrates the efficacy of BCP/BCS graft for bone augmentation in dehiscence-type extraction socket defect.
COMPLEX SITUATIONS ON IMPLANT DENTISTRY: SPECIALIZED CLINICAL SOLUTIONS
This is the official book of IN 2013 Latin American Congress. It presents clinical and scientific aspects on implant-supported prostheses, regenerative therapies, biomateriais, craniofacial surgery, CAD/CAM esthetics, immediate implant loading, and ongoing concepts for the pratice of dental implants. More than 40 authors share their high-skilled minds and clinical views on this rich-illustrated project.
Chapter 1
Prosthetically-driven alveolar reconstructions – the next step
Luiz Roberto Figueiredo Dantas, Mario Groisman, Guaracilei Maciel Vidigal Junior
Chapter 2
Challenges on the immediate implant-supported rehabilitation in the esthetic zone
Elken Gomes Rivaldo, Luis Carlos da Fontoura Frasca
Chapter 3
Soft tissue conditioning with esthetic implants: technique and scientific aspects
Carlos dos Reis Pereira de Araujo, Maria Angélica Rehder de Araujo, Fernanda Herrera Stancari
Chapter 4
A protocol to preserve the alveolar architecture for different biotypes using the granulation tissue
José Geraldo Malaguti, Franco Ignáccio Malaguti
Chapter 5
The subcrestal positioning for implant-supported restorations
Valdir Antônio Muglia, Arthur Belém Novaes Júnior
Chapter 6
Regenerative, therapeutic, and restorative delicate decisions: when the days are not enough
Paulo Martins Ferreira, Felipe Ramalho Ferreira, Gabriel Ramalho Ferreira, Renato Oliveira Ferreira da Silva, Paulo Henrique Orlato Rossetti, Wellington Cardoso Bonachela, Eduardo Batitucci, Luiz Fernando Pegoraro, Rubens Florino Pandolfi (in memoriam)
Chapter 7
Treatment of peri-implantitis using L-PRF and Er, Cr:YSGG laser in the esthetic zone: longitudinal aspects
Jamil Awad Shibli, Alberto Blay, Samy Tunchel, Leandro Roth, Gustavo Nardegam, Alessandra Cassoni, José Augusto Rodrigues
Chapter 8
Dental implant rehabilitation in the anterior esthetic zone: an approach to success
Juliano Milanezi de Almeida, Alvaro Francisco Bosco, Edgard Franco Moraes Jr., Letícia Helena Theodoro, Valdir Gouveia Garcia
Chapter 9
Reconstructive methods in the severely atrophic maxillary arch: clinical and scientific backgrounds
Samuel Porfírio Xavier, Antonio Azoubel Antunes, Cássio de Barros Pontes, Luiz Antonio Salata
Chapter 10
The implant-supported restorative dentistry: foundations, technology, and communication
Franco Rocha Villela
Chapter 11
Correction of large defects in the esthetic zone: why a multidisciplinary approach is mandatory?
Laércio Wonhrath Vasconcelos, Paulo Fukashi Yamaguti, Daniel Afonso Hiramatsu, Rafael Calçada Bastos Vasconcelos
Background: Post-extraction alveolus undergoes resorption. Decreased bone volume affects restoring the missing tooth and surrounding tissues.
The objective of this investigation was to determine the fate of thin buccal bone encasing the prominent roots of maxillary anterior teeth following extraction. Resorption of the buccal plate compromises the morphology of the localized edentulous ridge and makes it challenging to place an implant in the optimal position for prosthetic restoration. In addition, the use of Bio-Oss as a bone filler to maintain the form of the edentulous ridge was evaluated. Nine patients were selected for the extraction of 36 maxillary anterior teeth. Nineteen extraction sockets received Bio-Oss, and seventeen sockets received no osteogenic material. All sites were completely covered with soft tissue at the conclusion of surgery. Computerized tomographic scans were made immediately following extraction and then at 30 to 90 days after heating so as to assess the fate of the buccal plates and resultant form of the edentulous sites. The results were assessed by an independent radiologist, with a crest width of 6 mm regarded as sufficient to place an implant. Those sockets treated with Bio-Oss demonstrated a loss of less than 20% of the buccal plate in 15 of 19 test sites (79%). In contrast, 12 of 17 control sockets (71%) demonstrated a loss of more than 20% of the buccal plate. In conclusion, the Bio-Oss test sites outperformed the control sites by a significant margin. No investigator was able to predict which site would be successful without the grafting material even though all were experienced clinicians. This leads to the conclusion that a patient has a significant benefit from receiving grafting materials at the time of extraction.
The aim of this review was to evaluate the techniques and outcomes of postextraction ridge preservation and the efficacy of these procedures in relation to subsequent implant placement.
A MEDLINE/PubMed search was conducted and the bibliographies of reviews from 1999 to March 2008 were assessed for appropriate studies. Randomized clinical trials, controlled clinical trials, and prospective/retrospective studies with a minimum of five patients were included.
A total of 135 abstracts were identified, from which 53 full-text articles were further examined, leading to 37 human studies that fulfilled the search criteria. Many different techniques, methodologies, durations, and materials were presented in the publications reviewed, making direct comparison difficult.
Despite the heterogeneity of the studies, it was concluded that ridge preservation procedures are effective in limiting horizontal and vertical ridge alterations in postextraction sites. There is no evidence to support the superiority of one technique over another. There is also no conclusive evidence that ridge preservation procedures improve the ability to place implants.
The objective of this review was to evaluate the efficacy of different grafting protocols for the augmentation of localized alveolar ridge defects.
A MEDLINE search and an additional hand search of selected journals were performed to identify all levels of clinical evidence except expert opinions. Any publication written in English and including 10 or more patients with at least 12 months of follow-up after loading of the implants was eligible for this review. The results were categorized according to the presenting defect type: (1) dehiscence and fenestration-type defects, (2) horizontal ridge augmentations, (3) vertical ridge augmentations, and (4) maxillary sinus floor elevations using the lateral window technique or transalveolar approach. The review focused on: (1) the outcome of the individual grafting protocols and (2) survival rates of implants placed in the augmented bone.
Based on 2,006 abstracts, 424 full-text articles were evaluated, of which 108 were included. Eleven studies were randomized controlled clinical trials. The majority were prospective or retrospective studies including a limited number of patients and short observation periods. The heterogeneity of the available data did not allow identifying one superior grafting protocol for any of the osseous defect types under investigation. However, a series of grafting materials can be considered well-documented for different indications based on this review. There is a high level of evidence (level A to B) to support that survival rates of implants placed in augmented bone are comparable to rates of implants placed in pristine bone.
This study compared the dimensional alterations, the need for sinus floor elevation, and the histologic wound healing of augmented and nonaugmented alveolar sockets. Sixteen human extraction sockets were either grafted or left untreated. At baseline and 3 and 6 months postextraction, alveolar ridge alterations were evaluated; at 3, 6, and 9 months, histologic analyses were conducted. Implant placement with or without sinus floor augmentation was decided at 6 months. Three of eight patients in the control group underwent sinus floor augmentation compared to one of six in the experimental group. The alveolar ridge augmentation procedure presented here increases the possibility of inserting implants without the need for a sinus augmentation procedure.
The preservation of bone volume immediately after tooth removal might be necessary to optimize the success of implant placement in terms of esthetics and function. The objectives of this randomized clinical trial were two-fold: 1) to compare the bone dimensional changes following tooth extraction with extraction plus ridge preservation using corticocancellous porcine bone and a collagen membrane; and 2) to analyze and compare histologic and histomorphometric aspects of the extraction-alone sites to the grafted sites.
Forty subjects who required tooth extraction and implant placement were enrolled in this study. Using a computer-generated randomization list, the subjects were randomly assigned to the control group (EXT; extraction alone) or to the test group (RP; ridge-preservation procedure with corticocancellous porcine bone and collagen membrane). The following parameters were assessed immediately after extraction and 7 months prior to implant placement: plaque index, gingival index, bleeding on probing, horizontal ridge width, and vertical ridge changes. A bone biopsy was taken from the control and test sites 7 months after the surgical treatment. Histologic and histomorphometric analyses were also performed.
A significantly greater horizontal reabsorption was observed at EXT sites (4.3+/-0.8 mm) compared to RP sites (2.5+/-1.2 mm). The ridge height reduction at the buccal side was 3.6+/-1.5 mm for the extraction-alone group, whereas it was 0.7+/-1.4 mm for the ridge-preservation group. Moreover, the vertical change at the lingual sites was 0.4 mm in the ridge-preservation group and 3 mm in the extraction-alone group. Forty biopsies were harvested from the experimental sites (test and control sites). The biopsies harvested from the grafted sites revealed the presence of trabecular bone, which was highly mineralized and well structured. Particles of the grafted material could be identified in all samples. The bone formed in the control sites was also well structured with a minor percentage of mineralized bone. The amount of connective tissue was significantly higher in the extraction-alone group than in the ridge-preservation group.
The ridge-preservation approach using porcine bone in combination with collagen membrane significantly limited the resorption of hard tissue ridge after tooth extraction compared to extraction alone. Furthermore, the histologic analysis showed a significantly higher percentage of trabecular bone and total mineralized tissue in ridge-preservation sites compared to extraction-alone sites 7 months after tooth removal.
Various materials have been used immediately following tooth extraction to fill and/or cover the socket in an attempt to limit or prevent ridge resorption. The purpose of the present pilot study was to establish a reliable model to investigate the effect of various bone graft and bone replacement materials on extraction socket healing. This study also compared healing extraction sockets 6 to 8 months postimplantation of a bioactive glass (BG) or demineralized freeze-dried bone allograft (DFDBA) to an unfilled socket control (C).
Following tooth extraction, a total of 30 sockets in 19 patients were randomly divided into 3 treatment groups: 10 sockets received BG, 10 sockets DFDBA, and 10 sockets served as unfilled controls. Primary coverage was achieved by flap advancement over each socket. Six to 8 months postextraction at time of implant placement, histological cores of the treatment sites were obtained. These cores were processed, undecalcified sections prepared and stained with Stevenel blue/van Gieson's picric fuchsin, and histomorphometrically analyzed. Vital bone, connective tissue and marrow, and residual graft particles were reported as a percentage of the total core.
A model system was described in humans and used to evaluate the healing response in the 3 treatment groups. Results concluded that mean vital bone present was 59.5% for BG-, 34.7% for DFDBA-, and 32.4% for C-treated sites. These differences were not statistically significant. However, the residual implant material was significantly higher in DFDBA-treated (13.5%) versus BG-treated sockets (5.5%).
Although the differences in percent vital bone were not statistically significant among the 3 treatment groups in this pilot study, BG material was observed to act as an osteoconductive material which had a positive effect on socket healing at 6 to 8 months postextraction. Further research following implant placement in treated and control sockets is warranted to determine if bone implant contact is improved in BG-filled versus unfilled sockets.
Preservation of alveolar bone volume following tooth extraction facilitates subsequent placement of dental implants and leads to an improved esthetic and functional prosthodontic result. The aim of the present study was to assess bone formation in the alveolus and the contour changes of the alveolar process following tooth extraction. The tissue changes after removal of a premolar or molar in 46 patients were evaluated in a 12-month period by means of measurements on study casts, linear radiographic analyses, and subtraction radiography. The results demonstrated that major changes of an extraction site occurred during 1 year after tooth extraction.
Following tooth extraction, remodeling and resorption of the alveolar bone at the extraction site characterize wound healing. This produces a reduction in ridge volume and difficulties in delayed placement of implants in an ideal position. Medical grade calcium sulfate hemihydrate (MGCSH) has been proposed as a graft material in extraction sockets to minimize the reduction in ridge volume. The aim of the present study was to investigate the influence of MGCSH on the histopathologic pattern of intrasocket regenerated bone and to evaluate histologically the healed MGCSH grafted extraction socket site 3 months postextraction
MGCSH was grafted in 10 fresh human extraction sockets in 10 patients. Five post-extraction sockets were used as controls. At 3 months a cylindrical tissue specimen, 2.5 mm in diameter, was trephined from the previously grafted site followed by implant placement. Non-decalcified specimens were sectioned at a cross-horizontal plane and stained with fast green, toluidine blue, and Van Kossa stains for histological and histomorphometrical examination.
Histologically, MGCSH was not observed in most of the specimens. Newly formed bone with lamellar arrangements was identified in all the horizontal sections with no difference between apical, medium, and coronal areas. The mean trabecular area in the coronal sections was 58.6% +/- 9.2%; in the medium sections, 58.1% +/- 6.2%; and in the apical sections, 58.3% +/- 7.8%. The differences were not statistically significant.
MGCSH seems to be an ideal graft material in extraction socket bone regeneration because it is almost completely resorbable, and it allows a new trabecular bone arrangement at 3 months.
Conventional dentoalveolar osseous reconstruction often involves the use of grafting materials with or without barrier membranes. The purpose of this study was to evaluate the efficacy of bone induction for the placement of dental implants by two concentrations of recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered on a bioabsorbable collagen sponge (ACS) compared to placebo (ACS alone) and no treatment in a human buccal wall defect model following tooth extraction.
Eighty patients requiring local alveolar ridge augmentation for buccal wall defects (> or =50% buccal bone loss of the extraction socket) of the maxillary teeth (bicuspids forward) immediately following tooth extraction were enrolled. Two sequential cohorts of 40 patients each were randomized in a double-masked manner to receive 0.75 mg/ml or 1.50 mg/ml rhBMP-2/ACS, placebo (ACS alone), or no treatment in a 2:1:1 ratio. Efficacy was assessed by evaluating the amount of bone induction, the adequacy of the alveolar bone volume to support an endosseous dental implant, and the need for a secondary augmentation.
Assessment of the alveolar bone indicated that patients treated with 1.50 mg/ml rhBMP-2/ACS had significantly greater bone augmentation compared to controls (P < or =0.05). The adequacy of bone for the placement of a dental implant was approximately twice as great in the rhBMP-2/ACS groups compared to no treatment or placebo. In addition, bone density and histology revealed no differences between newly induced and native bone.
The data from this randomized, masked, placebo-controlled multicenter clinical study demonstrated that the novel combination of rhBMP-2 and a commonly utilized collagen sponge had a striking effect on de novo osseous formation for the placement of dental implants.
Extraction of a tooth necessitated by factors such as developmental problems, trauma, severe periodontal disease and endodontic problems often causes deformities of the residual alveolar ridge in the maxillary anterior region. These cases are usually difficult to restore prosthetically and they result in poor esthetics and insufficient occlusal function. This study investigated the efficacy of root form bioactive glass cones implanted into (a) artificial sockets produced by bone splitting of previous extraction sites (group BS) and (b) fresh extraction sockets (group FES), We included conventional extraction sockets sutured without implanting the root form bioactive glass cones as a control (group C). A total of 16 patients were treated for whom extractions had been indicated due to severe periodontitis, 6 patients with 7 implant sites having Class II or III alveolar ridge deformities comprised the BS group. 5 patients with 10 implant sites comprised the FES group. Group C, comprised 5 patients with 10 extraction sites. Alveolar ridge width and height measurements were obtained using study casts preoperatively, immediately postoperatively. and at 3 and 12 months after operation. In the BS group, while the width of the alveolar ridge increased by 2.8 ± 1.18mm immediately after ridge augmentation procedure and by 2.4±0.93 mm at 1 year after operation (p<0.01), the height of the alveolar ridge increased by 1.8±1.99 mm and 1.4±1.74 mm respectively (p<0.05). In the FES group, the differences between preoperative original ridge height and width and postoperative measurements were not statistically significant, which demonstrated the efficiency of this method in preserving the alveolar ridge. In group C, while alveolar ridge width after 12 months had not Significantly changed, alveolar ridge height decreased significantly (1.35±1.05 mm. p<0.01). After 12 months, no dehiscences were detected and the differences in height between the groups remained significant. The results of this study indicate that this procedure is efficient in reconstructing alveolar ridges deformed as a result of extraction, particularly relevant in relation to preparation for subsequent restorative treatment.
Reduction of alveolar height and width after tooth extraction may provide some problems in implant placement, especially in the anterior maxilla for esthetic reasons. Different graft materials have been advocated to prevent bone-volume reduction. The aim of this study was to evaluate radiographic parameters of implants positioned in grafted alveoli with three different biomaterials: magnesium-enriched hydroxyapatite (MHA), calcium sulfate (CS), and heterologous porcine bone (PB).
In 15 patients, 45 fresh extraction sockets with three bone walls were selected. Fifteen sockets received MHA, 15 sockets received CS, and 15 sockets received corticocancellous PB as a graft material. Three months after bone filling, titanium dental implants were placed in grafted sites. Three months after implant placement, temporary restoration was performed. Follow-up examinations were conducted, and intraoral digital radiographs were taken at baseline and 12 and 24 months after implant placement to evaluate the marginal bone level in each patient. Comparisons for marginal bone loss over time between groups were performed by the Student two-tailed t test.
At the 24-month follow-up, a survival rate of 100% was reported for all implants. For the MHA group, a mean mesial bone loss of -0.21 +/- 0.08 mm and a mean distal bone loss of -0.22 +/- 0.09 mm (mean bone loss: 0.21 +/- 0.09 mm) were reported; for the CS group, a mesial bone loss of -0.14 +/- 0.07 mm and a distal bone loss of -0.12 +/- 0.11 mm (mean bone loss: -0.13 +/- 0.09 mm) were measured; for the PB group, a mean mesial bone loss of -0.15 +/- 0.10 mm and a mean distal bone loss of -0.16 +/- 0.06 mm (mean bone loss: -0.16 +/- 0.08 mm) were reported. No statistically significant differences were reported among groups (P >0.05).
At the 24-month follow-up, the present study showed that placement of implants in grafted sockets was not influenced by the three different biomaterials because they did not negatively impact the clinical outcome.
The efficacy of solid cones of hydroxylapatite ceramic implanted in fresh extraction sockets for the preservation of alveolar bone was evaluated. Ten experimental subjects (70 implants) and eight control subjects (63 extractions) were treated. After extraction, hydroxylapatite ceramic cones were inserted into the sockets at least 1 mm below the alveolar crest in the experimental group. Alveolar ridge resorption was measured on lateral cephalometric radiographs, and statistical analysis was performed. The follow-up periods ranged from 12 to 24 months (mean, 20.6 months). Thirty-seven of the 70 hydroxylapatite ceramic cone implants (53%) became exposed, and 19 cones (27%) had to be removed. It was concluded that hydroxylapatite ceramic cone implants placed in fresh extraction sockets do not significantly preserve alveolar bone.
Preservation of the alveolar process after tooth extraction is desirable because it facilitates placement of endosseous implants and minimizes adverse esthetic results associated with fixed partial dentures. The purpose of this study was to evaluate the clinical effectiveness of bioactive glass used as a graft material combined with calcium sulfate used in the form of a mechanical barrier in preserving alveolar ridges after tooth extraction.
Sixteen patients who required extraction of 2 anterior teeth or bicuspids participated in the study (split mouth design). After tooth extraction and elevation of a buccal full-thickness flap, experimental sockets were filled with bioactive glass, which in turn was covered with a layer of calcium sulfate. Control sites did not receive any graft or calcium sulfate. Titanium pins served as fixed reference points for measurements. No attempt was made to advance the flap to cover the socket areas on control or experimental sites (open socket approach). Reentry surgeries were performed at 6 months.
Reentry surgeries showed that experimental sites presented with (1) significantly more internal socket bone fill (6.43 +/- 2.78 mm vs 4.00 +/- 2.33 mm on control sites), (2) less (although not statistically significantly less) resorption of alveolar bone height (0.38 +/- 3.18 mm vs 1.00 +/- 2. 25 mm on control sites), and (3) similar degree of horizontal resorption of the alveolar bony ridge as compared with controls (3. 48 +/- 2.68 mm vs 3.06 +/- 2.41 mm on control sites).
This study suggests that treatment of extraction sockets with a combination of bioactive glass and calcium sulfate is of some benefit in preserving alveolar ridge dimensions after tooth extraction.
The aim of this study was to investigate the healing of human extraction sockets filled with Bio-Oss particles (Geistlich Pharma AG, Wolhusen, Switzerland). In 21 subjects, providing a total of 31 healing sites, at least one tooth was scheduled for extraction and the extraction sites for implant therapy. The dimensions of the alveolar ridge at the extraction sites were considered insufficient and required augmentation concomitant with tooth extraction. There were three treatment groups. In group A, the extraction sockets were covered with a Bio-Gide membrane (Geistlich Pharma AG) and in group B the extraction sockets were filled with Bio-Oss. The extraction sockets in group C were left to heal spontaneously. Biopsies from the extraction sites were collected at the time of implant installation. Samples from group A showed large amounts of lamellar bone and bone marrow and small proportions of woven bone. Sites grafted with Bio-Oss (group B) were comprised of connective tissue and small amounts of newly formed bone surrounding the graft particles. Only 40% of the circumference of the Bio-Oss particles was in contact with woven bone. Sites from group C were characterized by the presence of mineralized bone and bone marrow.
Tooth extraction typically leads to loss of ridge width and height. The primary aim of this 6-month randomized, controlled, blinded, clinical study was to determine whether ridge preservation would prevent post-extraction resorptive changes as assessed by clinical and histologic parameters.
Twenty-four patients, 10 males and 14 females, aged 28 to 76 (mean 51.5 +/- 13.6), requiring a non-molar extraction and delayed implant placement were randomly selected to receive either extraction alone (EXT) or ridge preservation (RP) using tetracycline hydrated freeze-dried bone allograft (FDBA) and a collagen membrane. A replaced flap, which did not completely cover the sockets, was used. Following extraction, horizontal and vertical ridge dimensions were determined using a modified digital caliper and an acrylic stent, respectively. Prior to implant placement, a 2.7 x 6.0 mm trephine core was obtained and preserved in formalin for histologic analysis.
The width of the RP group decreased from 9.2 +/- 1.2 mm to 8.0 +/- 1.4 mm (P<0.05), while the width of the EXT group decreased from 9.1 +/- 1.0 mm to 6.4 +/- 2.2 mm (P<0.05), a difference of 1.6 mm. Both the EXT and RP groups lost ridge width, although an improved result was obtained in the RP group. Most of the resorption occurred from the buccal; maxillary sites lost more width than mandibular sites. The vertical change for the RP group was a gain of 1.3 +/- 2.0 mm versus a loss of 0.9 +/- 1.6 mm for the EXT group (P<0.05), a height difference of 2.2 mm. Histologic analysis revealed more bone in the RP group: about 65 +/- 10% versus 54 +/- 12% in the EXT group. The RP group included both vital bone (28%) and non-vital (37%) FDBA fragments.
Ridge preservation using FDBA and a collagen membrane improved ridge height and width dimensions when compared to extraction alone. These dimensions may be more suitable for implant placement, especially in areas where loss of ridge height would compromise the esthetic result. The quantity of bone observed on histologic analysis was slightly greater in preservation sites, although these sites included both vital and non-vital bone. The most predictable maintenance of ridge width, height, and position was achieved when a ridge preservation procedure was employed.
The placement of different graft materials and/or the use of occlusive membranes to cover the extraction socket entrance are techniques aimed at preserving/reducing alveolar ridge resorption. The use of grafting materials in fresh extraction sockets has, however, been questioned because particles of the grafted material have been found in alveolar sockets 6-9 months following their insertion.
The aims of the study were to (i). evaluate whether alveolar ridge resorption following tooth extraction could be prevented or reduced by the application of a bioabsorbable polylactide-polyglycolide sponge used as a space filler, compared to natural healing by clot formation, and (ii). evaluate histologically the amount and quality of bone tissue formed in the sockets, 6 months after the use of the bioabsorbable material.
Thirty-six patients, undergoing periodontal therapy, participated in this study. All patients were scheduled for extraction of one or more compromised teeth. Following elevation of full-thickness flaps and extraction of teeth, measurements were taken to evaluate the distance between three landmarks (mesio-buccal, mid-buccal, disto-buccal) on individually prefabricated stents, and the alveolar crest. Twenty-six alveolar sockets (test) were filled with a bioabsorbable polylactide-polyglycolide acid sponge (Fisiograft), while 13 sockets (controls) were allowed to heal without any filling material. The flaps were sutured with no attempt to achieve primary closure of the surgical wound. Re-entry for implant surgery was performed 6 months following the extractions. Thirteen biopsies (10 test and three control sites) were harvested from the sites scheduled for implant placement.
The clinical measurements at 6 months revealed, in the mesial-buccal site, a loss of bone height of 0.2 mm (1.4 SD) in the test and 0.6 mm (1.1 SD) in the controls; in the mid-buccal portion a gain of 1.3 mm (1.9 SD) in the test and a loss of 0.8 mm (1.6 SD) in the controls; and in the distal portion a loss of 0.1 mm (1.1 SD) in the test and of 0.8 (1.5 SD) mm in the controls. The biopsies harvested from the test sites revealed that the new bone formed at 6 months was mineralized, mature and well structured. Particles of the grafted material could not be identified in any of the 10 test biopsies. The bone formed in the control sites was also mature and well structured.
The results of this study indicate that alveolar bone resorption following tooth extraction may be prevented or reduced by the use of a bioabsorbable synthetic sponge of polylactide-polyglycolide acid. The quality of bone formed seemed to be optimal for dental implant insertion.
To study dimensional alterations of the alveolar ridge that occurred following tooth extraction as well as processes of bone modelling and remodelling associated with such change.
Twelve mongrel dogs were included in the study. In both quadrants of the mandible incisions were made in the crevice region of the 3rd and 4th premolars. Minute buccal and lingual full thickness flaps were elevated. The four premolars were hemi-sected. The distal roots were removed. The extraction sites were covered with the mobilized gingival tissue. The extractions of the roots and the sacrifice of the dogs were staggered in such a manner that all dogs contributed with sockets representing 1, 2, 4 and 8 weeks of healing. The animals were sacrificed and tissue blocks containing the extraction socket were dissected, decalcified in EDTA, embedded in paraffin and cut in the buccal-lingual plane. The sections were stained in haematoxyline-eosine and examined in the microscope.
It was demonstrated that marked dimensional alterations occurred during the first 8 weeks following the extraction of mandibular premolars. Thus, in this interval there was a marked osteoclastic activity resulting in resorption of the crestal region of both the buccal and the lingual bone wall. The reduction of the height of the walls was more pronounced at the buccal than at the lingual aspect of the extraction socket. The height reduction was accompanied by a "horizontal" bone loss that was caused by osteoclasts present in lacunae on the surface of both the buccal and the lingual bone wall.
The resorption of the buccal/lingual walls of the extraction site occurred in two overlapping phases. During phase 1, the bundle bone was resorbed and replaced with woven bone. Since the crest of the buccal bone wall was comprised solely of bundle this modelling resulted in substantial vertical reduction of the buccal crest. Phase 2 included resorption that occurred from the outer surfaces of both bone walls. The reason for this additional bone loss is presently not understood.
Various grafting materials have been used for preservation of the dimensions of the residual alveolar ridge following tooth extraction. The purpose of this study was to evaluate clinical, histomorphometric, and radiographic healing 4 months after tooth extraction with or without placement of a putty-form anorganic bovine-derived hydroxyapatite matrix combined with a synthetic cell-binding peptide P-15 (Putty P15) to determine the effect on alveolar ridge preservation following exodontia.
Twenty-four consecutive subjects in need of extraction of maxillary premolars were recruited. Recruited subjects were randomly assigned to the test (Putty P15 and bioabsorbable collagen wound dressing material) or control (bioabsorbable collagen wound dressing material only) group. Data were recorded at 1, 2, 4, 8, and 16 weeks after ridge preservation procedures. At 16 weeks, a reentry surgery was performed, clinical measurements were repeated, and bone core biopsies were obtained for histomorphometric analysis prior to dental implant placement.
The control group had a mean reduction in ridge height of -0.56 +/- 1.04 mm, whereas alveolar ridge height appeared to remain unchanged in the test group (0.15 +/- 1.76). The test group showed a mean reduction in ridge width of -1.31 +/- 0.96 mm, whereas the mean value for the control group was -1.43 +/- 1.05 mm. No statistical significance was observed between the groups. Mean bone density was significantly superior in the test group (2.08 +/- 0.65 versus 3.33 +/- 0.65). Histomorphometric analyses revealed similar percentages of bone vitality (test: 29.92% +/- 8.46%; control: 36.54% +/- 7.73%). Comparable percentages of bone marrow and fibrous tissue also were observed (test: 65.25% +/- 6.41%; control: 62.67% +/- 7.41%). Only 6.25% of the Putty P15 particles remained at 4 months in the analyzed biopsies.
A favorable response was observed when Putty P15 was applied to extraction sockets, suggesting that it may be useful for alveolar ridge preservation prior to dental implant placement.
Clinical and histomorphometric evaluation of extraction sockets treated with an autologous bone marrow graft
- Aa Pelegrine
- Ce Da Costa
- Me Correa
- Marques Jr
Pelegrine AA, da Costa CE, Correa ME, Marques Jr JF. Clinical and histomorphometric evaluation of extraction sockets
treated with an autologous bone marrow graft. Clin Oral
Implants Res 2010;21:535-542.
Clinical and histomorphometric evaluation of extraction sockets treated with an autologous bone marrow graft
- A A Pelegrine
- C E Da Costa
- M E Correa
- Marques Jr
Pelegrine AA, da Costa CE, Correa ME, Marques Jr JF. Clinical and histomorphometric evaluation of extraction sockets
treated with an autologous bone marrow graft. Clin Oral
Implants Res 2010;21:535-542.