Documente Academic
Documente Profesional
Documente Cultură
REVIEW
doi:10.1111/j.1834-7819.2007.00008.x
ABSTRACT
The resorption of bone following extraction may present a significant problem in implant and restorative dentistry. Ridge
preservation is a technique whereby the amount of bone loss is limited. This paper discusses the scientific literature
examining the healing post-extraction and ridge preserving techniques, primarily from the perspective of implant dentistry.
Some indications for ridge preservation and methods considered appropriate are discussed.
Key words: Extraction, bone resorption, grafting, membranes, implants.
Abbreviation: ePTFE = expanded polytetrafluoroethylene.
(Accepted for publication 26 March 2007.)
INTRODUCTION
Internal changes
Prerequisites for successful implant therapy are integration of the implant, ideal implant position and
appropriate hard and soft tissue contours. These
require sufficient alveolar bone volume and favourable
ridge architecture coupled with an appropriate surgical technique. However, following extraction of teeth
the alveolar ridge resorbs, the rate of which may vary
between sites and subjects. This may result in
inadequate bone volume and unfavourable ridge
architecture for dental implant placement (Figs 1
and 2).
The aim of this article is to discuss events
following extraction and how these can be optimized
to facilitate successful implant therapy. The same
principles may be applied to edentulous areas in
order to enhance aesthetic outcomes for fixed bridges
and removable dentures. However, the primary focus
of this article is to improve the outcome of implant
therapy.
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I Darby et al.
Ridge preservation
techniques are based on the principles of guided
tissue bone regeneration. Many procedures have been
suggested including minimally traumatic tooth extraction, soft and hard tissue grafting, concomitant use of
barrier membranes and immediate implant placement.
(a)
(b)
(a)
I Darby et al.
whilst others suggest that a round bur should be used to
perforate the socket walls a number of times to allow
greater access for blood vessels into the socket and any
grafting material in an attempt to improve bony infill.14
Conversely, it has been shown in an experimental study
that retention of the periodontal ligament along the
socket walls facilitated retention of the clot during the
early stages of wound healing.15 Thus, apart from
removal of chronically inflamed tissue and foreign
materials, extensive debridement or perforation of the
socket walls may not be required.
Coverage of the socket by soft tissue
The literature is divided over whether soft tissue
coverage of the socket at the time of extraction is
necessary for optimum healing of the socket and
aesthetics. Soft tissue coverage procedures may be
considered to retain, stabilize and protect grafting
materials. It is a critical step when using non-resorbable
membranes. Many techniques have been suggested and
include displacing neighbouring tissue to cover the
socket, such as coronal advancement of a buccal flap,
rotating grafts from tissue adjacent to cover the defect,
or using free gingival or subepithelial connective tissue
grafts.1618 Alternatively, the site may be left for six to
eight weeks to allow healing and regeneration of
mucosa over the socket. The added volume of soft
tissue at this stage may facilitate optimum closure over
the socket when ridge preservation procedures are
undertaken. In a similar manner, procedures allowing
spontaneous soft tissue proliferation could be considered prior to extraction to increase soft tissue coverage,
such as removing the crown and burying the remaining
root.19 The Bio-Col technique20 involves the placement
of an anorganic bovine bone graft (Bio-Oss) protected
by a resorbable collagen sponge (Collaplug see below)
and then allowing spontaneous epithelialization of
the socket under a denture tooth or bridge pontic.
Table 1. Summary of the studies quoted investigating ridge preservation using bone grafts only, membranes only or
a combination
Method used
Bone Graft only
Membranes only
14
Authors
Material(s) used
Outcome
Resolut
Ridge preservation
Post-surgery the patient may experience considerable
discomfort in the donor.
A study using DFDBA23 showed that DFDBA cannot
speed up bone formation. Both Becker et al.22 and
Froum et al.24 showed little new bone formed around
DFDBA. It is not available in Australia, but it is often
mentioned in studies from North America and included
here for the sake of completeness.
Recently, Artzi et al.25 used a common porous
bovine bone graft (Bio-Oss) in 15 fresh extraction
sockets, covering the graft with soft tissue and
re-entering nine months later. They reported that
there was 82.3 per cent bone infill and all sites
allowed safe insertion of fixtures. Histologic appearance showed a mixture of Bio-Oss and new bone
formation, increasing in bone fraction apically. The
use of a xenograft does not require a donor site, thus
reducing morbidity following harvesting and simplifying the procedure. Figure 5 shows Bio-Oss placed in
an extraction socket.
Hydroxyapatite use in fresh extraction sockets in a
series of 23 cases was reported by Nemcovsky and
Serfaty.26 They achieved primary closure by rotating
split thickness flaps and were followed for 24 months.
They showed that there was predictable ridge preservation with minimal postoperative ridge deformation
(1.4 mm vertically and 0.6 mm horizontally). This
would retain sufficient bone volume to allow implants
to be inserted. However, over half the patients experienced some exfoliation of hydroxyapatite suggesting
that the flap design was not predictable in maintaining
soft tissue closure. A bioactive glass (Biogran) was
investigated in fresh extraction sockets by Froum
et al.24 and compared to control sockets and those
with DFDBA. All sites were covered by flap advancement and re-entered six to eight months later. The
placement of Biogran resulted in 60 per cent bone
I Darby et al.
Membranes only
It is also possible to cover the socket to prevent ingress
of soft tissue, thereby promoting maximal bony healing. Generally, there are two types of membrane used,
resorbable and non-resorbable. Table 1 summarizes the
papers quoted in this article. In 1997, Lekovic et al.7
investigated the use of a non-resorbable expanded
polytetrafluoroethylene (ePTFE) membrane to maintain
the alveolar ridge after extraction. Two sites each in 10
patients were used, one site receiving a membrane and
the other site as a control. All sockets were debrided
and flaps displaced to cover the membrane and socket.
Reassessment took place at six months, with significantly greater loss of bone height and width in the
control group and more infill in the ePTFE group.
However, 30 per cent of membranes became exposed
and this resulted in similar results to the control group.
Giving the high rate of exposure, this paper suggests the
use of ePTFE membranes should perhaps be avoided.
Figure 6 shows the use of an ePTFE membrane.
A later paper by the same group8 looked at the use of
a resorbable membrane compared to a control site in 16
patients. A polyglycolide lactide membrane (Resolute,
WL Gore & Associates) was placed and reassessed at
six months. The experimental sites showed significantly
less loss of alveolar bone height, more internal socket
fill and less horizontal resorption of the ridge. Importantly, there were no exposures. Therefore, it seems that
resorbable membranes should be preferred over nonresorbable. Unfortunately, the authors did not report
on whether the ridges were suitable for implants
irrespective of technique, which limits the usefulness
of these papers. Although an animal-derived membrane, Bio-Gide is available in Australia and used
widely in clinical periodontal practice. We are unaware
of any ridge preservation studies reporting its use, but
there seems to be no reason why it could not be used
in this manner. Figure 7 shows the placement of a
Bio-Gide membrane.
Bone grafts and membranes together
Ridge preservation
however, the American Academy of Periodontology
(AAP) issued a notice describing the recall of one
particular brand due to incomplete medical information
regarding the origin of the graft.
Interestingly, Fugazzotto33 in a report on a comparison of resorbable and titanium-reinforced membranes
used with Bio-Oss found that significant bucco-lingual
ridge collapse was noted upon re-entry. The findings
of this paper are supported by the work of Zubillaga
et al.34 who showed that tacked membranes in place
results in less loss of augmented bone than non-tacked
membranes.
Other space fillers
It appears that insertion of a filler material into the
socket is important to preserve as much bone as
possible, but does it always have to be a bone graft?
In addition, the presence of graft particles at time of
placement may not be desirable. Serino and co-workers35 placed in 36 patients a commercially available
bioabsorbable sponge of polylactide-polyglycolide. The
teeth were surgically extracted, sockets debrided, the
sponge inserted and flaps replaced with no primary
closure. Six months later all sites were reassessed and
implants placed. There were 26 test sockets and 13
control. All test sockets healed with less bone resorption than the controls especially in the mid-buccal
region. The authors suggested that the sponge served as
a support to prevent the collapse of the surrounding
soft tissue into the socket during the healing process. A
similar product is available commercially in Australia
and is a collagen plug (Collaplug, Zimmer Dental). This
and the sponge above can be placed into the socket
without raising a flap, but there is little research in this
area and the materials may only act to stabilize the clot
and not to preserve the ridge. Figure 8a shows
Collaplug before it is placed, Fig 8b after placement
in the socket and Fig 8c demonstrates healing after
three weeks.
(a)
(b)
(c)
I Darby et al.
then this may not matter at all as long as there is
enough bone initially, but this may cause problems
later especially in aesthetic areas if there is buccal tissue
loss.39
The future
Given the current advances in stem cell technology we
may in the future be able to place tooth buds in sockets
to regrow teeth or place a cellular scaffold in the socket
to maintain the bone. Cultivated scaffolds from bone
marrow mesenchymal stem cells have been placed
into fresh extraction sockets with results that show
promise.40
Complications
It needs to be mentioned that any surgical procedure
may have complications. These commonly are postoperative pain and swelling, and occasionally infection.
Any surgery on the gingival tissues will cause some
recession. It is well known that in GTR procedures
up to 70 per cent of non-resorbable membranes may
become exposed to the oral environment, severely
reducing the amount of new tissue formed.41 In
addition, Girard et al.42 reported a case of a foreign
body granuloma following placement of a graft into an
extraction socket with pain and sensation disturbance.
It should be noted that the site was already compromised by previous infection and may serve as a
reminder to debride sockets fully or not to undertake
preservation in the presence of infection.
DISCUSSION
Although the literature presents a confusing picture
with difficulty in comparing studies, ridge preservation
does appear to limit the loss of hard and soft tissue at
extraction sites, and can provide less bone loss compared to non-preserved sites. While there were extraction-only sites that were suitable for implant therapy,
the most predictable maintenance of ridge width, height
and position was achieved using ridge preservation.
Ideally, a technique for socket preservation ought to be
easy to use, not involve surgery, leave no residual
foreign bone particles, involve no floppy membranes
likely to collapse into the socket and result in no bone
loss. However, it appears that no material or technique
fully meets these criteria.
The authors experience with Collaplug (Zimmer) is
that, after six to eight weeks, resorption is similar to
that seen in a normal extraction socket; the material
therefore does not seem to do much to preserve the
ridge. The PGA PLA plug reported by Serino et al.35
may have been designed to have a much slower
resorption rate.
18
Ridge preservation
Is implant placement
being considered
within the next 6 to 8
weeks?
NO....Why no?
Is the site extremely compromised,
the buccal plate more than 2 mm
thick, bone volume does not have to
be maintained or have previous
extraction sites healed up well?
NO.... the
socket walls
are intact and
significant
resorption is
not
anticipated in
the following
6 to 8 weeks
no graft
required
I Darby et al.
have to be raised in some cases. Much may depend on
the general health and habits of the patient, such as
smoking.
13. Hammerle CHF, Chen ST, Wilson TG. Consensus statements and
recommended clinical procedures regarding the placement of
implants in extraction sockets. Int J Oral Maxillofac Implants
2004;19(Suppl):2628.
CONCLUSIONS
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Ridge preservation
33. Fugazzotto PA. GBR using bovine bone matrix and resorbable
and nonresorbable membranes. Part 1: Histologic results. Int J
Periodontics Restorative Dent 2003;23:361369.
34. Zubillaga G, Von Hagen S, Simon BI, Deasy MJ. Changes in
alveolar bone height and width following post-extraction ridge
augmentation using a fixed bioabsorbable membrane and demineralised freeze-dried bone osteoinductive graft. J Periodontol
2003;74:965975.
35. Serino G, Biancu S, Iezzi G, Piattelli A. Ridge preservation following tooth extraction using a polylactide and polyglycolide
sponge as space filler: a clinical and histological study in humans.
Clin Oral Implants Res 2003;14:651658.
36. Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Ridge alterations
following implant placement in fresh extraction sockets: an experimental study in the dog. J Clin Periodontol 2005;32:645652.
37. Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement at extraction sites. J Clin
Periodontol 2004;31:820828.
38. Chen ST, Darby IB, Adams GG, Reynolds EC. A prospective
clinical study of bone augmentation techniques at immediate
implants. Clin Oral Implants Res 2005;16:176184.
39. Araujo MG, Wennstrom JL, Lindhe J. Modeling of the buccal
and lingual bone walls of fresh extraction sites following
21