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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 13  |  Issue : 3  |  Page : 115-120

Socket preservation techniques: An overview with literature review


Department of Periodontology and Implantology, Indira Gandhi Institute of Dental Sciences, Puducherry, India

Date of Submission22-May-2022
Date of Decision30-Jul-2022
Date of Acceptance02-Aug-2022
Date of Web Publication09-Sep-2022

Correspondence Address:
Dr. Elsie Sunitha Ebenezer
No. 32, Veeramamuniver Street, Dr. Radhakrishnan Nagar, Gorimedu, Puducherry - 605 509
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/srmjrds.srmjrds_79_22

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  Abstract 

Background: Alveolar bone undergoes residual ridge resorption after tooth extraction and eventually results in inadequate soft tissue and alveolus for dental implant rehabilitation. Therefore, to overcome this, socket preservation is performed immediately after tooth extraction to maximize bone formation within the socket. Aim: This review is aimed to give a brief overview of rationale, indications, surgical techniques, decision tree, and recent literature evidence regarding different techniques of socket preservation. Methods: An electronic search was performed in databases such as PubMed, Scopus, and Google Scholar with the key words socket preservation, particulate bone grafts, membranes, and platelet-rich fibrin. The articles published from August 2008 to February 2022 were included for the search. Results: A total of 18 articles were considered for the review which included 8 meta-analysis, 7 systematic review, and 3 randomized control trial. The outcome parameters such as clinical, radiographical, and histomorphometrical ridge dimensions were analyzed. Conclusion: Socket preservation is one of the effective treatment options to prevent bone resorption following an atraumatic extraction with the use of appropriate biomaterials and membranes. The reliability and power of evidence is strong for the combined technique of using bone graft and membrane.

Keywords: Membranes, particulate bone grafts, platelet-rich fibrin socket preservation


How to cite this article:
Ebenezer ES, Muthu J, Balu P, Kumar R S. Socket preservation techniques: An overview with literature review. SRM J Res Dent Sci 2022;13:115-20

How to cite this URL:
Ebenezer ES, Muthu J, Balu P, Kumar R S. Socket preservation techniques: An overview with literature review. SRM J Res Dent Sci [serial online] 2022 [cited 2022 Sep 30];13:115-20. Available from: https://www.srmjrds.in/text.asp?2022/13/3/115/355828


  Introduction Top


Alveolar bone uneventfully undergoes residual ridge resorption after tooth extraction.[1] Socket preservation is a procedure which is done to reduce external ridge resorption following tooth extraction and enhances bone formation within the socket.[1],[2],[3] It is usually done immediately following tooth extraction or it is delayed for a period of 6–8 weeks due to some reasons like the presence of acute infections. A recent study reports that after 6–8 weeks after tooth extraction alveolar ridge undergoes minimal dimensional changes.[4]

The first step is preoperative patient assessment and treatment planning, which includes selection of appropriate technique, suitable biomaterial, timing of augmentation, and duration of implant placement (staged versus simultaneous). The preoperative evaluation includes systemic health status and local factors such as morphology of soft tissue and alveolar ridge volume, ridge contour, and neighboring teeth position of marginal bone. To scan the defect, three-dimensional imaging such as computed tomography, panoramic radiography, and intraoral radiographs can be utilized. Lack of adequate soft-tissue coverage causes insufficient primary tension-free closure over the site of augmentation. Socket grafting during the time of extraction will limit bone resorption.[5]

This review gives a brief overview of rationale, indications, surgical techniques, decision tree, and recent literature evidence regarding the different techniques of socket preservation.


  Methods Top


An electronic search was performed in databases such as PubMed, Scopus, and Google scholar with the key words socket preservation, particulate bone grafts, membranes, and platelet-rich fibrin (PRF). The articles published from August 2008 to February 2022 were included for the search.


  Results Top


A total of 18 articles were considered for the review which included 8 meta-analysis, 7 systematic review, and 3 randomized control trial. The outcome parameters such as clinical, radiographical, and histomorphometrical ridge dimensions were analyzed.


  Discussion Top


There are several classifications proposed for extraction socket. Elian et al.[6] proposed a simplified classification which helps to determine the bone quality following extraction based on the presence of buccal and palatal hard and soft tissues. This classification is simplified which helps the clinicians for better documentation and treatment and helps clinicians to decide if socket surgery is indicated or not whether an immediate or delayed implanted is needed or not.

  • “Type I socket: The facial soft tissue and buccal plate of the bone are at normal levels in relation to the cementoenamel junction of the preextracted tooth and remain intact postextraction
  • Type II socket: Facial soft tissue is present, but the buccal plate is partially missing following extraction of the tooth
  • Type III socket: The facial soft tissue and the buccal plate of the bone are both markedly reduced after tooth extraction.”[6]


Type I sockets does not require any augmentation procedure and can be treated with immediate or delayed implant. Type II and III sockets require socket treatment due to deficient buccal cortical bone and should be treated as staged approach due to socket healing additional soft and hard tissue surgery are required before implant placement.[6]

Decision tree for preservation of extraction socket

The indication for preservation of extraction socket is as follows:[7]

  • Decreases alveolar ridge atrophy after tooth extraction for implant prosthesis treatment
  • Immediate implant placement indicated in fresh extraction sockets having one wall defect requiring adequate buccal cortical plate
  • Restoration of bony defects caused by infection, trauma, and traumatic extractions
  • Anterior teeth with buccal bone thickness is ≤2 mm
  • Areas in close proximity to anatomic structures (maxillary sinus and mandibular canal).


The contraindication for the preservation of extraction socket is as follows:[7]

  • Medical conditions that preclude implant placement[7]
  • Extracted socket with bony lesions of more than 5 mm where future implant cannot be placed[7]
  • It is not advisable when there is molar root-penetrating maxillary sinus[7]
  • In cases of maxillary alveolar process atrophy and nasal floor projection can cause risk of nasal floor perforation.[7]


Preservation of extraction socket is broadly planned as two zones based on the location as esthetic anterior zone and nonesthetic posterior zone. In esthetic zones, esthetic considerations are investigated such as facial soft-tissue deficiency, absence of buccal wall of extraction socket ≥50%, and horizontal bone loss ≥2 mm. Functional considerations are if primary stability cannot be achieved, at least ≤3 mm of bone to be present beyond apex of extraction socket and contact of implant and bony walls.

In nonesthetic zones, the following esthetic considerations are checked like facial soft tissue deficiency surrounding extraction socket, absence of buccal wall of extraction socket, and horizontal bone loss ≥3 mm. Similarly, functional considerations are if primary stability cannot be achieved, at least ≤3 mm of bone to be present beyond apex of extraction socket and absence of septal bone [Table 1].[8]
Table 1: Clinical decision tree for extraction socket/augmentation

Click here to view


Socket preservation techniques

Socket preservation technique can be categorized by the following biomaterials such as

  1. Ridge preservation by only bone grafts
  2. Ridge preservation by membrane only
  3. Combined technique


  1. Particulate bone graft with resorbable membrane
  2. Particulate bone graft with PRF.


Ridge preservation by only bone grafts

Many grafting materials are used, which include autograft (oral or extraoral), allograft (e.g. human freeze-dried bone), Xenograft (bovine or porcine), and Alloplasts or synthetic materials (hydroxyapatite, tricalcium phosphate, and bioactive glass), which are placed in a thoroughly debrided fresh extraction sockets.[9],[10] The “gold standard” among these grafting materials is autogenous bone.[11] Becker et al.[11] compared particulate alloplasts against autogenous bone in seven paired sites finding that after 3 months new bone was formed at sites where autogenous bone was placed, but not in sites using alloplasts. Common intra-oral sites to harvest autogenous bone are around the surgical site, ascending ramus, chin, and maxillary tuberosity.

Ridge preservation by the membrane only

Only membranes were placed on the socket to prevent migration of the soft tissue, which promotes bone healing. The membranes are classified into two types: resorbable and nonresorbable. Atraumatic extraction is carried under adequate local anesthesia to preserve ridge. Bioresorbable/nonresorbable materials are placed inside an extraction socket and sutured.[10]

Combined technique

The following are the methods of combined technique[11],[12],[13]

  1. Particulate bone graft with resorbable membrane
  2. Particulate bone graft with PRF.


Literature evidence for socket preservation

The articles included in this review differed in techniques, material used like, bone grafts, membrane, combination of both bone graft, and membrane and second-generation platelet concentrates. The bone gain/fill is evaluated by using various methods such as clinical vertical and horizontal ridge width, radiographic assessment, histological and histomorphometric analysis [Table 2].
Table 2: Literature evidence for socket preservation

Click here to view


Socket preservation will limit residual ridge resorption and prepare the alveolus for dental implant rehabilitation. In lieu with the above several studies had been done to assess the postoperative dimensional changes after socket preservation compared with natural extraction socket healing. Most commonly utilized techniques for socket preservation are bone graft alone, membrane alone, and combined technique.

On comparing the evidence which incorporated particulate bone graft and membrane, socket preservation reduced the resorption of hard tissue ridge after tooth extraction compared to extraction alone.[14],[16],[21],[22],[29] Some studies found no beneficial effects of socket grafting compared to natural socket healing.[17],[20],[28] Ten Heggeler et al.[15] stated that socket preservation resulted in greater bone height gain with concurrent width loss.

Kassim et al.[19] assessed the healing time and time of implant placement which resulted in delayed healing associated with ridge preservation using socket grafting necessitates a commitment to a delayed placement protocol. Also, stated that the extended treatment time, compromised healing and expense related to ridge preservation suggests a more cautious approach with regard to the indication of such approaches.

Corning and Mealey[24] histologically compared two biomaterials; freeze dried bone allograft and solvent dehydrated bone allograft following tooth extraction for ridge preservation and stated that no significant benefit with the use of either freeze dried bone allograft or solvent dehydrated bone allograft.

Galindo-Moreno et al.[25] assessed quantitative and qualitative influence of two different factors: membranes and soft-tissue graft influence for the socket preservation which stated that membranes had better results compared to soft-tissue graft. Furthermore, in another study by Chatzopoulos et al.[30] evaluated the efficacy of dense – Polytetrafluroethylene (dPTFE) membranes when used alone or in combination with bone grafting materials for socket preservation which states that the use of dPTFE membranes was better than extraction alone in terms of keratinized tissue width and radiographic vertical bone loss.

A few authors had utilized platelet concentrates, especially PRF alone or along with particulate bone grafts for socket preservation and stated that PRF in extraction sites mainly improves soft-tissue healing and offered greater percentages of bone fill.[18],[23],[27],[31] One study by Lin et al.[26] stated that PRF alone in ridge preservation did not provide significant additional benefit when compared to natural healing sockets.

On analyzing literature to preserve extraction socket, clear potential of socket preservation therapies is demonstrated over the natural healing of the socket. The following techniques were widely used: bone graft alone, membrane alone, and combined technique. Among these techniques, the reliability and power of evidence is strong for the combined technique (i.e., use of bone graft and membrane) and for PRF. However, there are no enhanced benefits of using PRF in socket preservation because of scare evidence and so further research is essential to substantiate the utilization and contribution to prevent residual ridge resorption after tooth extraction.


  Conclusion Top


Socket preservation is one of the effective treatment options to prevent bone resorption following an atraumatic extraction with the use of appropriate biomaterials and membranes. The reliability and power of evidence is strong for the combined technique (i.e., use of bone graft and membrane). Evidence points that the use of PRF in extraction sites mainly improves soft-tissue healing and evidence for its potential to enhance alveolar bone volume is still scarce. There is no additional benefit of using only PRF in ridge preservation when compared natural healing socket.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Chen ST, Wilson TG Jr., Hämmerle CH. Immediate or early placement of implants following tooth extraction: Review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19 Suppl:12-25.  Back to cited text no. 4
    
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Elian N, Cho SC, Froum S, Smith RB, Tarnow DP. A simplified socket classification and repair technique. Pract Proced Aesthet Dent 2007;19:99-104.  Back to cited text no. 6
    
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Juodzbalys G, Stumbras A, Goyushov S, Duruel O, Tözüm TF. Morphological classification of extraction sockets and clinical decision tree for socket preservation/augmentation after tooth extraction: A systematic review. J Oral Maxillofac Res 2019;10:e3.  Back to cited text no. 8
    
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Barone A, Aldini NN, Fini M, Giardino R, Calvo Guirado JL, Covani U. Xenograft versus extraction alone for ridge preservation after tooth removal: A clinical and histomorphometric study. J Periodontol 2008;79:1370-7.  Back to cited text no. 14
    
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Ten Heggeler JM, Slot DE, Van der Weijden GA. Effect of socket preservation therapies following tooth extraction in non-molar regions in humans: A systematic review. Clin Oral Implants Res 2011;22:779-88.  Back to cited text no. 15
    
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Kassim B, Ivanovski S, Mattheos N. Current perspectives on the role of ridge (socket) preservation procedures in dental implant treatment in the aesthetic zone. Aust Dent J 2014;59:48-56.  Back to cited text no. 19
    
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21.
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24.
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30.
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31.
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