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INVITED REVIEW
Year : 2015  |  Volume : 7  |  Issue : 3  |  Page : 73-80

Socket augmentation


1 Department of Periodontics, MM College of Dental Sciences and Research, Mullana, Haryana, India
2 Department of Periodontics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India

Date of Web Publication31-Dec-2015

Correspondence Address:
Shalu Chandna
782, Sector - 13, Urban Estate, Karnal - 132 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0754.172937

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   Abstract 

Introduction of dental implants have come to the forefront of modern odontology. A successful osseointegration demands an ideal quantity and quality of alveolar bone. Socket augmentation techniques are effective in minimizing postextraction alveolar ridge resorption. The aim of this paper is to review the available literature on socket augmentation with special focus on its relation with implant.

Keywords: Alveolar resorption, extraction, socket augmentation


How to cite this article:
Chandna S, Kaur K, Kaur N, Manocha A. Socket augmentation. J Int Clin Dent Res Organ 2015;7, Suppl S1:73-80

How to cite this URL:
Chandna S, Kaur K, Kaur N, Manocha A. Socket augmentation. J Int Clin Dent Res Organ [serial online] 2015 [cited 2019 Sep 17];7, Suppl S1:73-80. Available from: http://www.jicdro.org/text.asp?2015/7/3/73/172937


   Introduction Top


Successfully osseointegrated implants essentially require adequate quality and quantity of bone at the implant site. Once a tooth is extracted, the alveolar ridge inevitably undergoes remodeling with associated resorption and diminished size of the ridge. It leads to compromises in the functional and aesthetic outcomes of implant and thus, hard and soft tissue augmentations are needed.[1],[2]

The first documentation of postextraction bone loss was by Greenstein in 1985 and Ashman and Bruins (1985).[3] For the prevention of bone loss and reduction of it to acceptable levels, many surgical techniques and modalities have been proposed: Atraumatic extraction and immediate implant placement are the first and foremost methods as far as the surgical approach is concerned. However, it has been postulated that flap elevation affects alveolar dimensional alterations only in the short term while no significant differences were found in the long term.[4] In cases where immediate implant placement is contraindicated such as periapical infection, it is often worth contemplating socket augmentation.[5]

Socket preservation is preserving the socket/ridge volume within the socket confines existing at the time of extraction.

Socket augmentation is increasing the socket/ridge volume beyond the socket confines or skeletal envelope existing at the time of extraction.[6]


   Results of Tooth Extraction Top


  1. Alveolar ridge resorption — Horizontal (buccal and lingual) and vertical.
  2. More resorption on buccal/facial side than on the lingual/palatal.
  3. Three-dimensional resorption leads to narrow ridge, reduced vertical height, and linguopalatal shifting of the long axis.



   Long-Term Sequelae of Extraction Top


  1. Defective ridge leads to incorrect placement of endosseous implants.
  2. Inappropriate prosthetic fabrication with poor aesthetic outcome.


After extraction, alveolar socket undergoes subsequent remodeling process, which is a means of natural additional atrophy. It begins as soon as the tooth is extracted and within a period of 3 months; almost 50% alveolar ridge gets resorbed.[7] Additional loss of bone occurs during/when the extraction is not performed atraumatically.

There has been extensive research on anatomical and physiological changes that take place after tooth extraction. Alveolar bony complexes are composed of: Basal bone (forms the body of the maxilla and mandible), alveolar process (contains tooth alveolus), and bundle bone (lines the alveolar socket).[8] Bone resorption occurs in two stages. The first phase involves rapid resorption of bundle bone and a greater reduction in bone height (especially in buccal aspect of the socket).[9] During the second phase of bone resorption, there is remodeling of the outer surface of alveolar bone causing overall horizontal and vertical tissue contractions. The continuous remodeling process reduces the vertical ridge height and the ridge morphology is more palatal in relation to the original tooth's position. The resorption rate has been found to be highest in the first 6 months of tooth extraction,[9],[10] and continues at an average of 0.5-1% per year throughout life.[11],[12] It has been seen that there is a reduction in the width of the ridge between 2.6 mm and 4.6 mm and height in the range of 0.3-3.9 mm.[13]

Postextraction alveolar resorption is significantly more on the buccal surfaces. This may be due to labial anatomy of the alveolar bone, which is thin and knife-edged. Thin buccal cortical bone undergoes average resorption up to 0.8 mm in the anterior teeth and 1.1 mm in the premolar sites,[13] leading to unfavorable conditions for implant placement.


   Indications for Socket Augmentation Top


  1. When immediate or early implantation is not recommended.[14]
  2. Deficient buccal cortical plate: The presence of fenestration and dehiscence amplifies the postextraction osseous remodeling, resulting in buccal concavity in the alveolar bone.[15] Thus, it seems judicious to prevent alveolar socket destruction and make efforts to preserve the ridge after extraction.
  3. Areas where esthetics is important: The most important consideration in the aesthetic zone is to preserve marginal soft-tissue contours. Tooth extraction alone in the areas with thin labial bone results in loss of labial plate and soft tissue collapse into the extraction socket, which results in the loss of bone volume and gingival contour.[7],[15],[16] Socket augmentation help to optimize bony fill within the extraction socket. Maintenance of vertical bone height helps to stabilize the soft tissues at the extraction site. This stabilized and improved soft tissue contour marginally improves implant placement with a high degree of predictability in the aesthetic area.[17],[18]
  4. In adolescent people contouring of the ridge for conventional prosthetic treatment.[15]
  5. Reducing the need for elevation of the sinus floor.[15]



   Procedure Top


Over the years, untiring efforts have been made by many scientists to develop methods and modalities to preserve the sockets successfully [Table 1]. Various techniques have been documented for socket preservation, e.g., Bio-Col technique,[27] sandwich technique.[28]
Table 1: Studies related to grafted and nongrafted socket

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Steps for Socket Preservation (the Bio-Col technique):[27]

  1. Atraumatic extraction [Figure 1].
  2. Perforation of the socket wall to create a bleeding surface.
  3. Condensation of deproteinized bovine bone xenograft filled to the osseous crest: A material with osteoconductive properties and slow rate of resorption (Bio-Oss or other synthetic material) placed into the socket.
  4. Placement of a resorbable collagen matrix material over the graft preserves sufficient volume and contour to permit subsequent implant placement and achievement of acceptable esthetic results [Figure 2].
  5. Horizontal mattress suture over the extraction site so as to retain the graft and collagen matrix.
  6. Cyanoacrylate placed over the suture and collagen to harden the material and decrease permeability of this barrier.
  7. Placement of an ovate pontic into the surgery site.


The various regenerative biomaterials for socket augmentation are grafts, membranes, biologic modifiers, and platelet concentrates [Table 2]. The methods, which are employed to increase the rate of bone formation and to augment socket belong to either of these four basic categories: Osteoinduction (use of growth factors), osteoconduction (grafting materials acts as a scaffold for new bone growth), distraction osteogenesis (surgically induced fracture and pulling apart of bone fragments), and guided tissue regeneration (space maintenance by barrier membranes, which get filled with new bone).[35]
Figure 1: atraumatic extraction socket

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Figure 2: membrane is placed over the graft and sutured

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Table 2: Studies related to socket grafting materials

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Soft-tissue grafts

Free soft-tissue graft minimizes the soft tissue shrinkage of the augmented alveolar socket and preserves the graft from bacterial infections and secondary graft failure.[36],[37] Landsberg and Bichacho first described the socket graft with an autogenous soft-tissue implant.[38] Nevins and Mellonig suggested soft-tissue grafts to improve ridge topography after tooth extraction.[39] Tal described the survival of circular connective tissue grafts placed over extraction sockets treated either with demineralized freeze-dried bone allograft (DFDBA) or Bio-Oss and found that more often partially vital grafts maintained their vitality over the socket area more than on the graft margins. It was concluded that the nourishment could be originated from plasmatic elements in the socket blood clot more than from vessels originating from the periphery of the graft.[40]

Bone grafts

There are numerous therapeutic grafting modalities and are classified according to their original source as follows: Autograft, allograft, xenograft, and alloplastor synthetic materials.

Autogenous

These grafts are transferred from one position to another within the same individual. Autogenous bone grafts can be harvested from intraoral or extraoral sites and can be cortical bone or cancellous bone. Autogenous bone is certainly the best since it may have both osteogenetic and osteoinductive potencies. A study conducted by Kim YK evaluated the clinical efficacy of autogenous tooth bone graft material in the alveolar ridge preservation of an extraction socket and it was shown to be a favorable bone substitute due to evidenced good bone remodeling and osteoconductivity.[4]

Allografts

These grafts are transferred between genetically dissimilar members of the same species. These are categorized as DFDBA or mineralized freeze-dried bone (FDBA). A study conducted in 2000 evaluated extraction sockets grafted with deproteinized bovine bone mineral (DBBM) at 9 months and it was found that DBBM was still present. Also, DBBM was found to be a favorable graft for ridge preservation when compared to irradiated cancellous allograft, and to solvent-dehydrated allograft when used to preserve extraction sockets.[41] Wood and Mealey gave the first histologic and clinical evidence when they conducted a study with 40 extraction sockets, which were grafted with DFDBA or FDBA. During implant placement at 4-5 months, histologic samples revealed that DFDBA had a significantly greater percentage of vital bone at 38.42% and lower mean percentage of residual graft particles versus FDBA at 24.63%.[31] Eskow and Mealey enrolled 40 patients to compare histological and clinical healing following tooth extraction and ridge preservation with the use of cortical and cancellous FDBA and it was seen that although new bone formation did not differ between the two groups, greater percentage of residual graft material was found in the cortical group.[34]

Alloplasts

They are synthetic or inorganic implant materials, which are used as substitutes for bone graft and function primarily as defect fillers. These are namely polymers, tricalcium phosphate, and hydroxyapatite and bioactive glasses. Froum et al. evaluated extraction sockets grafted with hydroxyapatite and found vital bone to be approximately 31% present at 6-8 months.[29] However, as far as the comparison with allograft is concerned, Jensen et al. studied autograft and allograft bone healing and reabsorption of β-tricalcium phosphate (β-TCP) into an organic bovine bone and it was demonstrated that both β-TCP and allograft retard bone regeneration in the early healing phase as compared with autograft. Thus, it was concluded that both these substitutes can be replaced with autografts in bone reconstruction surgery, especially where variable biodegradability is a requirement.[42] Mehdi Sezavar compared alloplast with allograft in terms of preservation and bone regeneration of the alveolar ridge after tooth extraction and found both materials to be equal in terms of the quantity and the quality of osteoblasts and no major difference could be found between these two groups with respect to the regenerated bone.[43]

Xenografts

These are grafts taken from a donor of another species. A human study by Eskow, Mealey using 25 patients compared placing Bio-Oss collagen into intact extraction sockets versus controls in 39 sites. After 12 weeks, augmented sites showed new bone formation, which was only 25% compared to nonaugmented sites.[34] This suggests a delay in bone formation in the grafted sites as found in other studies.

Membranes

Various barrier membranes used for socket augmentation are either nonresorbable or resorbable and are used alone or in combination with bone grafts. A barrier membrane is placed to aid in the containment of graft particles within the extraction socket while soft tissue healing is taking place, especially when there is no primary closure through a coronally advanced flap or the addition of a connective tissue graft. A resorbable barrier membrane is recommended. Collagen barrier with a short resorption time may be employed as epithelialization takes place within the first 2-3 weeks after extraction. Barrier membrane in socket preservation is not for the purpose of guided bone regeneration (GBR). Thus, a GTR barrier membrane may be required when labial bone loss is identified prior to tooth extraction. Whenever a socket has one or more bony walls missing or damaged, it will be necessary to contemplate GBR.[5]

Lekovic et al. examined the effect of glycolide and lactide polymer membranes showing reduced loss of alveolar height, more internal bone socket bone fill, and less horizontal resorption than the controls.[17] Luczyszyn et al. evaluated the effect of acellular dermal matrix with or without a resorbable hydroxyapatite graft and it was seen that the combination worked better.[30]

Neiva et al. evaluated the healing of extraction sockets covered with a resorbable collagen membrane and by the employment of various modalities such as subtraction radiography, μ-computed tomography (CT) analysis, and the use of histological evaluation, adequate bone formation was demonstrated with implant placement as early as 12 weeks following tooth extraction, with insignificant changes in the alveolar ridge dimensions.[44]

A case-control study included patients with 39 healed extraction sites were treated with socket preservation and delayed implant placement. Subjects had a bone replacement graft and a barrier membrane placed at the time of tooth extraction. Results of the study indicate that bone density may be similar between grafted and nongrafted sites following healing.[26] The findings of this study correlate well with the systematic review by Horvath et al. on the comparison of alveolar ridge preservation versus unassisted socket healing.[5]


   Biologic Modifiers and Platelet Concentrates Top


Platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are autologous thrombocyte concentrates. These are obtained through direct centrifugation from the patient's blood and should be applied as quickly as possible.



Gupta et al. implemented utilization of alloplasts with autologous PRF for socket preservation for implant placement and it was concluded that socket preservation surgery employing the use of bioceramics and PRF is an effective procedure for posterior socket preservation coupled with rapid healing and helps in increasing the quality of bone for successful implant placement.[45] Moraschini Vin evaluated the effect of autologous platelet concentrates in preservation of sockets and the plasma concentrates were found to accelerate healing and soft tissue epithelialization in extraction sockets and reduce postoperative pain and discomfort.[46] However, there is no evidence to date to confirm that plasma concentrates improve hard tissue regeneration. Ayoub and Ramadan compared PRF and mineralized plasmatic matrix (MPM) for socket preservation and found that the integration of bone graft materials with autologous growth factors (fibrin, platelets, and leukocytes) in the form of MPM showed better histologic evidence of bone formation after 4 months than the use of PRF as sole filling material for the extraction socket.[47]


   Discussion Top


The aim of the paper was to review the histological data healing patterns following tooth extraction in terms of socket bone quality, percentage, and residual graft as compared with physiological healing processes at the nongrafted sites.

During the first phase of healing, initially the blood clot, subsequently the granulation tissue, and later the provisional matrix and the immature woven bone fill up the alveolus. Complete resorption of bundle bone causes reduction in the vertical height. Later in the second phase, the buccal wall and the woven bone are remodeled causing horizontal and further vertical bone reductions.[48] When socket augmentation is done, the first phase and vertical bone reduction still occurs; however, the second phase and the horizontal contraction are reduced.[23],[24],[25]

The most important factor in determining the choice of graft material is based on the number of remaining walls of the bone; the more missing walls of bone, the more is the need to incorporate autogenous bone in the grafting site [Chart 1].

Each graft material offers different characteristics and advantages.[49] Allograft is an an osteoinductive material that offers an improved handling properties and gives a well contained grafted site.[50],[51] The time required for xenogenic grafts to resorb has brought its use as extraction socket graft material into question.[2],[52] When immediate implant is not planned, it is best to place nonresorbabale graft employ nonresorbable material.[53]

Several studies have investigated studies, investigate the efficacy of various bone graft materials used for socket augmentation. Froum et al. demonstrated that acellular dermal matrix allograft (ADMA)-covered sites showed more vital bone than observed in expanded polytetrafluoroethylene (ePTFE)-covered sockets regardless of the bone resorption material used.[29] Bartee stated that nonresorbable materials have been reported as not suitable graft material in sockets to receive implant body.[54] During early socket healing, these nonresorbable xenograft particles get enclosed in connective tissue coated by multinucleated cells when nongrafted or resorbable grafted sites show newly formed woven bone occupying most of the socket.[55] This response is typical of a foreign body reaction in which only partial resorption of the grafted particles occurred, which in turn delayed early socket healing.[56] According to the literature, xenograft and alloplast showed the highest amount residual graft particles [29],[31] while autograft showed the lowest.[30] This gives rise to doubts on the achievement of the osseointegration of dental implants placed at xenografts and nonresorbable grafted sites and thus, suggest a hypothetical clinical preference in case of graft selection.


   Conclusion Top


Whichever method is used, extraction socket preservation is an additional procedure performed in the patient to preserve and augment the alveolar housing so that sufficient quantity and quality of bone remain to perform successful implant surgery and thus, improve its efficacy. Thus, the issues related to socket augmentation and prevention of edentulous jaw atrophy are of great concern for the same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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