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Socket sealing strategies for alveolar ridge preservation

Gabriel Magrin, Mariano Sanz, Juan Blanco-Carrion
Gabriel Magrin

Table of Contents

Background and objective

After tooth extraction, a remodeling process takes place in the alveolar socket, leading to volumetric changes that reduce bone availability for further dental implant placement. Why do dimensional alterations happen after tooth removal? Briefly, the periodontal ligament is lost during the alveolar healing process, which consequently affects the maintenance of the bundle bone (Araújo & Lindhe, 2005). Bundle bone is an anatomical structure in which periodontal ligament fibers insert. After tooth extraction, the periodontal ligament is lost and so is the bundle bone. As the bundle bone deteriorates, the alveolar bone that surrounds the tooth is resorbed, especially in individuals with a thin periodontal phenotype (Chappuis et al., 2013). This phenomenon is more intense in the first few months after tooth extraction, but it is continuous, and will progressively lead to a reduction in alveolar ridge volume, sometimes precluding an adequate implant-supported rehabilitation (Mardas et al., 2015). Therefore, some clinical strategies should be employed to compensate the post-extraction dimensional alterations of the alveolar ridge.

According to our philosophy, every time a patient presents a hopeless tooth, it is important to consider post-extraction immediate or early implant placement. However, alveolar ridge preservation has its indications, particularly when implant placement is to be delayed (Avila-Ortiz et al., 2020). Even though alveolar ridge preservation involves other important steps such as minimally invasive tooth extraction and filling the alveolar socket with a slowly resorbing biomaterial, our focus is on another important step: alveolar socket sealing. Hence, the objective of this report is to discuss three different approaches for sealing alveolar sockets in the context of alveolar ridge preservation.

Alveolar ridge preservation

Alveolar ridge preservation refers to a method that aims to minimize the loss of ridge dimensions after tooth extraction and avoid more demanding surgical procedures in the future. To accomplish this objective, placing a bone graft material into the post-extraction socket has been proposed in combination with socket sealing using autogenous soft tissue plugs or barrier membranes. Alternatively, non-autogenous matrices have been used to replace soft tissue grafts, thus reducing morbidity to patients since they exclude access to donor sites for tissue harvesting. In the case of a hopeless tooth with the decision to carry out an alveolar ridge preservation procedure, delayed implant placement can be performed six months after tooth removal (Avila-Ortiz et al., 2019).

Considering the clinical sequence for alveolar ridge preservation, our protocol starts with a flapless minimally invasive tooth extraction, carried out as gently as possible to minimize the inflammatory remodeling process due to surgical trauma. After cutting the gingival fibers with a scalpel, a periotome is used to luxate the tooth by cutting the periodontal ligament fibers, especially in the interproximal areas. Next, a vertical root extraction system can be employed to remove the fractured tooth, thus avoiding the use of elevators or forceps. First, a root canal is prepared, and then a traction system is attached to the tooth and the root is pulled out without putting pressure on the surrounding tissues, causing minimum trauma to neighboring structures. It is important to emphasize that minimally invasive extraction is critical in order to maintain the buccal bone wall and the interproximal papilla, which is crucial to the success of alveolar ridge preservation (Fig. 1).

Fig. 1: Minimally invasive tooth extraction. A) Intra-sulcular incision without papilla involvement; B) Tooth luxation with a periotome; C) Drill used to prepare the root canal for vertical extraction; D) Detail of the extraction system; E) Vertical extraction system ready for activation; F) Tooth being removed vertically; G) Tooth after removal; H) Fresh alveolar socket with preserved bone walls and soft tissues
Fig. 1: Minimally invasive tooth extraction. A) Intra-sulcular incision without papilla involvement; B) Tooth luxation with a periotome; C) Drill used to prepare the root canal for vertical extraction; D) Detail of the extraction system; E) Vertical extraction system ready for activation; F) Tooth being removed vertically; G) Tooth after removal; H) Fresh alveolar socket with preserved bone walls and soft tissues

The next step is to fill the fresh alveolar socket with a slowly resorbing biomaterial. We used a xenograft based on deproteinized bovine bone mineral with 10% collagen to improve its handling (Llanos et al., 2019). First, the biomaterial is moistened with saline solution and then sliced up with a sharp blade. Finally, the prepared biomaterial is introduced in the alveolar socket up to the apical portion. The remaining biomaterial is placed in the gaps inside the socket up to the level of the alveolar bone crest (Fig. 2). Once the socket is filled with the biomaterial, the socket opening should be closed – there is controversy on the most appropriate method (Avila-Ortiz et al., 2019). There are three possible approaches that we illustrate in this report: the use of a free autogenous soft tissue graft from the palate, an acellular collagen matrix, or a collagen membrane.

Fig. 2: Alveolar socket filling. A) Slowly resorbing biomaterial (demineralized bovine bone mineral with 10% collagen) moistened with saline solution; B) Slicing biomaterial with a sharp blade; C) Filling the socket with the biomaterial; D) Alveolar socket filled with biomaterial up to bone crest level
Fig. 2: Alveolar socket filling. A) Slowly resorbing biomaterial (demineralized bovine bone mineral with 10% collagen) moistened with saline solution; B) Slicing biomaterial with a sharp blade; C) Filling the socket with the biomaterial; D) Alveolar socket filled with biomaterial up to bone crest level

Case 1 – Free autogenous graft from the palate

The soft tissue from the palate is currently the reference and probably the most frequently used technique for socket sealing in alveolar ridge preservation. The procedure normally involves an incision in the palatal area, which may be performed with a punch blade or a scalpel corresponding to the oval outline of the socket. The tissue can be held with tweezers and the incision can be completed at the bottom of the tissue up to its removal. After the de-epithelialization of the marginal tissue of the receptor site with a scalpel or diamond bur, the epithelialized soft tissue graft is placed on the socket, over the bone substitute material, and sutured to the borders of the alveolar cavity in the receptor area. The objective of these sutures is to stabilize the autogenous graft during the first days or weeks after the surgical procedure. The nutrition of these grafts, however, is deficient, and two situations are possible in the postoperative follow-up: incorporation of the soft tissue graft, or necrosis of the grafted tissue. In most cases, granulation tissue forms underneath the soft tissue graft, which maintains the integrity of the biomaterial inside the alveolar socket. Nevertheless, the soft tissue graft may be lost too soon, exposing the bone substitute and impairing the bone formation inside the socket. Although not always present, one disadvantage of the autogenous graft is scar formation between graft and surrounding tissue, which may affect aesthetic outcomes (Fig. 3).

Fig. 3: Socket sealing with a free autogenous graft from the palate. A) Incision on the donor site with an 8-mm punch; B) After holding the soft tissue with tweezers, a scalpel is used to remove the graft; C) Soft tissue graft after removal; D) Soft tissue graft sutured on the receptor bed; E) One possible scenario is the soft tissue healing with incorporation of the graft (2-week follow-up); F) Another possible situation is the necrosis of the graft, which may not impair the results of the procedure if granulation tissue has formed under the graft to maintain the biomaterial inside the socket
Fig. 3: Socket sealing with a free autogenous graft from the palate. A) Incision on the donor site with an 8-mm punch; B) After holding the soft tissue with tweezers, a scalpel is used to remove the graft; C) Soft tissue graft after removal; D) Soft tissue graft sutured on the receptor bed; E) One possible scenario is the soft tissue healing with incorporation of the graft (2-week follow-up); F) Another possible situation is the necrosis of the graft, which may not impair the results of the procedure if granulation tissue has formed under the graft to maintain the biomaterial inside the socket

Case 2 – Collagen matrix

Some heterogenous and xenogenous matrices were developed as alternatives for free autogenous grafts. More recently, a collagen-based matrix was introduced in the market specifically for use sealing the alveolar socket. This porcine-derived material is constituted of two layers: a lower, spongy layer that is thicker, approximately 5 mm when dry; and a compact, upper layer that is thinner, approximately 1 mm thick, with a dense arrangement of collagen fibers.  This lower layer with open spaces between the struts of the collagen network is responsible for blood-clot stabilization, which may facilitate cell ingrowth and further tissue formation. On the other hand, in the upper part, the collagen fibers are tightly organized, which provides enough resistance when suturing the material to the surrounding tissues and delays the degradation process, which is good, since the material needs to remain in situ at least until healing tissue has formed (Sanz et al., 2009). To stabilize the collagen matrix on the surgical site, single interrupted sutures can be performed from the borders of the material to the soft tissues around the alveolar socket. Since this material loses its thickness when soaked, we recommend suturing the material dry, the collagen matrix will gradually become wet during suturing (Fig. 4).


Fig. 4: Socket sealing with a collagen matrix. A) Detail of a collagen matrix used for socket sealing; B) Collagen matrix sutured on the receptor bed
Fig. 4: Socket sealing with a collagen matrix. A) Detail of a collagen matrix used for socket sealing; B) Collagen matrix sutured on the receptor bed

Case 3 – Collagen membrane

There is solid evidence of good results with collagen membranes for guided bone regeneration and bone augmentation procedures (Naenni et al., 2019). However, their clinical performance for socket sealing is still controversial. Clinicians usually employ collagen membranes as a socket sealing material when defects of the alveolar bone walls are present. In these situations, collagen membranes are cut in the shape of the alveolar defect and placed over the bone substitute, with the borders of the membrane carefully adjusted under the marginal gingiva (Fig. 5). Even though some studies demonstrate the potential for the use of collagen membranes exposed to the oral cavity (Choi et al., 2017; Lim et al., 2019), this use does not have the same evidence of success as for guided bone regeneration. Exposure to the oral cavity may accelerate the degradation of the membrane, leading to early exposition of the bone substitutes inside the alveolar socket (Garcia et al., 2018).

Fig. 5: Socket sealing with a collagen membrane. A) Detail of a collagen membrane; B) After preparing the membrane, it can be carefully positioned under the marginal gingiva; C) View of the membrane sealing the socket; D) Compressive sutures to stabilize the collagen membrane
Fig. 5: Socket sealing with a collagen membrane. A) Detail of a collagen membrane; B) After preparing the membrane, it can be carefully positioned under the marginal gingiva; C) View of the membrane sealing the socket; D) Compressive sutures to stabilize the collagen membrane

Nevertheless, we can benefit from the use of collagen membranes in alveolar ridge preservation by employing the membrane as a secondary sealing material under a soft tissue graft or acellular matrix. In a clinical study, alveolar sockets were volumetrically preserved with xenogenous grafts and sealed with soft tissue pedicles from the palate, with or without collagen membranes underneath (Perelman-Karmon et al., 2012). The membrane-protected sockets showed increased bone formation as compared to unprotected sockets, suggesting that a “double sealing” strategy could be potentially interesting for alveolar ridge preservation procedures.

Concluding remarks

The socket sealing strategies proposed in this article, with autogenous graft, collagen matrix or collagen membrane, are very much alike in terms of their potential for assisting alveolar ridge preservation. We speculate that the socket sealing material has the single function of remaining in situ long enough for the formation of a granulation tissue beneath it, which would cover the graft material inside the socket and give way to keratinized mucosa after maturation. However, this hypothesis remains to be clarified in future research. Xenogenous biomaterials for socket sealing do not increase postoperative morbidity since they do not require surgical access to a donor site. However, clinicians should consider that biomaterials add costs to the treatment and the decision to replace autogenous grafting techniques must be taken on a case-by-case basis, according to the patients’ needs.

Authors

Gabriel Magrin
Gabriel Magrin DDS, MSc, PhD is a post-doctorate fellow in the Department of Dentistry at the Federal University of Santa Catarina (UFSC) in Brazil. He has 12 years of experience in dental practice with a focus on dental implants, periodontics, oral surgery, dental prostheses, and oral rehabilitation. He is currently an ITI Scholar in the Department of Periodontology at the Complutense University of Madrid, and the University of Santiago de Compostela, in Spain.
Mariano Sanz
Mariano Sanz MD, DDS, Dr. Med. is Professor of Periodontology and Director of the EFP Accredited Postgraduate Program Master in Periodontology at the Universidad Complutense de Madrid. He is President of the Oral Reconstruction Foundation. Mariano Sanz is an Associate Editor of the Scientific Journal of Clinical Periodontology. He lectures and has published more than 350 scientific articles and book chapters on periodontology, implant dentistry and dental education.
Juan Blanco-Carrión
Juan Blanco-Carrion MD, DDS, MSc, PhD has been a professor of periodontology at the School of Medicine and Dentistry of the University of Santiago de Compostela (USC) since 2008, where he is also the Director of the Master in Periodontology and Implantology as well as the Continuing Education Program in Periodontics. Juan Blanco-Carrion sits on the ITI Research Committee and is a former president of the European Federation of Periodontology and the Spanish Society of Periodontology.

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Avila-Ortiz, G, Gubler, M., Romero-Bustillos, M., Nicholas, C. L., Zimmerman, M. B., & Barwacz, C. A. (2020). Efficacy of Alveolar Ridge Preservation: A Randomized Controlled Trial. Journal of Dental Research, 99(4), 402–409. https://doi.org/10.1177/0022034520905660

Avila-Ortiz, Gustavo, Chambrone, L., & Vignoletti, F. (2019). Effect of alveolar ridge preservation interventions following tooth extraction: A systematic review and meta-analysis. Journal of Clinical Periodontology, 46 Suppl 2(S21), 195–223. https://doi.org/10.1111/jcpe.13057

Chappuis, V., Engel, O., Reyes, M., Shahim, K., Nolte, L.-P., & Buser, D. (2013). Ridge alterations post-extraction in the esthetic zone: a 3D analysis with CBCT. Journal of Dental Research, 92(12 Suppl), 195S-201S. https://doi.org/10.1177/0022034513506713

Choi, H.-K., Cho, H.-Y., Lee, S.-J., Cho, I.-W., Shin, H.-S., Koo, K.-T., Lim, H.-C., & Park, J.-C. (2017). Alveolar ridge preservation with an open-healing approach using single-layer or double-layer coverage with collagen membranes. Journal of Periodontal & Implant Science, 47(6), 372. https://doi.org/10.5051/jpis.2017.47.6.372

Garcia, J., Dodge, A., Luepke, P., Wang, H.-L., Kapila, Y., & Lin, G.-H. (2018). Effect of membrane exposure on guided bone regeneration: A systematic review and meta-analysis. Clinical Oral Implants Research, 29(3), 328–338. https://doi.org/10.1111/clr.13121

Lim, H.-C., Shin, H.-S., Cho, I.-W., Koo, K.-T., & Park, J.-C. (2019). Ridge preservation in molar extraction sites with an open‐healing approach: A randomized controlled clinical trial. Journal of Clinical Periodontology, 46(11), 1144–1154. https://doi.org/10.1111/jcpe.13184

Llanos, A. H., Sapata, V. M., Jung, R. E., Hämmerle, C. H., Thoma, D. S., César Neto, J. B., Pannuti, C. M., & Romito, G. A. (2019). Comparison between two bone substitutes for alveolar ridge preservation after tooth extraction: Cone‐beam computed tomography results of a non‐inferiority randomized controlled trial. Journal of Clinical Periodontology, 46(3), 373–381. https://doi.org/10.1111/jcpe.13079

Mardas, N., Trullenque-Eriksson, A., MacBeth, N., Petrie, A., & Donos, N. (2015). Does ridge preservation following tooth extraction improve implant treatment outcomes: a systematic review: Group 4: Therapeutic concepts & methods. Clinical Oral Implants Research, 26 Suppl 1, 180–201. https://doi.org/10.1111/clr.12639

Naenni, N., Lim, H. C., Papageorgiou, S. N., & Hämmerle, C. H. F. (2019). Efficacy of lateral bone augmentation prior to implant placement: A systematic review and meta-analysis. Journal of Clinical Periodontology, 46(S21), 287–306.

Perelman-Karmon, M., Kozlovsky, A., Liloy, R., & Artzi, Z. (2012). Socket site preservation using bovine bone mineral with and without a bioresorbable collagen membrane. The International Journal of Periodontics & Restorative Dentistry, 32(4), 459–465.

Sanz, M., Lorenzo, R., Aranda, J. J., Martin, C., & Orsini, M. (2009). Clinical evaluation of a new collagen matrix (Mucograft® prototype) to enhance the width of keratinized tissue in patients with fixed prosthetic restorations: A randomized prospective clinical trial. Journal of Clinical Periodontology, 36(10), 868–876. https://doi.org/10.1111/j.1600-051X.2009.01460.x

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