Intact extraction sockets that are not treated experience 1.4 mm reduction in buccal wall height and approximately 50% reduction in horizontal ridge width within the first 3 months of healing. 53% of all post-extraction sockets have dehiscences or fenestrations, however we know very little about how to repair these lesions. A well done meta analysis was published in 2020 and found only 6 studies that qualify as evidence based evaluations of the repair of buccal wall dehiscences.
Volumetric changes in alveolar ridge preservation with a compromised buccal wall: a systematic review and meta-analysis
The results of the six studies evaluated in the meta analysis are tabulated below:
Evidence Based Studies On
Buccal Wall Regeneration
Changes in bone width (mean ± standard deviation [SD])
Changes in height (mean ± standard deviation [SD])
The meta analysis showed an additional bone loss of 2.37 mm in width (p > 0.001) and 1.10 mm in height (p > 0.001) in the absence of bone grafting. While the grafted sites were significantly improved over non grafting, even when grafting materials were used the sites continued to lose bone width and height. Interestingly, while the profession continues to predominantly use allografts for repairing buccal dehiscences, the authors of this meta analysis could not find any scientific support for their use. Just as there are no scientifically valid studies for placing implants in sockets grafted with allografts, we can now add that there is also no scientific basis for grafting a dehiscence with allografts. However, one of the articles in this study did evaluate the performance of a synthetic and it was found to produce a statically significant improvement over no graft and with that evidence we will present a few cases where science-based bone graft materials are used to repair missing socket walls.
Root fracture with 100% loss of the buccal wall and 50% loss of the lingual wall.
10 months after grating with Socket Graft Plus and covering with a d-PTFE membrane. Flaps repositioned to original location to preserve keratinized gingiva, sutured and sealed with Oral Bond.
10 months after grafting, the clinical ridge is maintained with good keratinized tissue.
The regenerated bone is lighter in color. At this time frame, all surface βTCP granules are resorbed except at the apex of the previous lesion. The border of old and new bone is defined by the arrows.
The lingual wall is completely regenerated with some remaining granules. The buccal wall is regenerated with a minor depression at the crest.
Arrows denote the border between old bone and regenerated bone. A 3.6 mm diameter Astra implant is placed.
Primary closure is never complete around healing abutments, but primary closure is required on the buccal vertical incisions.
Post operative pain is commonly associated with sutures used to close buccal and lingual vertical releasing incisions as they rub against the cheek and tongue. For this reason, sutures are rarely indicated in these areas. Here, the open wound is closed with tissue pick-ups and Oral Bond, a sterile adhesive, is applied.
With the wound held closed, a drop of Oral Bond is applied.
Oral Bond after closure of the buccal flap.
On the lingual, a drop of Oral Bond is placed on the incision and a wet finger using the patient’s saliva is used to run over the incision to smooth out the Oral Bond and set it. Oral Bond is not placed around the healing abutments when primary closure is not possible. Oral Bond does not use sand as a thickener and therefore provides for a nonabrasive smooth surface.
A few pointers are necessary in order to achieve this level of regeneration:
- Only normal healthy vital bone has been shown to successfully support dental implants for the long term.
- Only a completely resorbable synthetic science-based bone graft can produce normal healthy vital bone.
- Any graft material that leaves residual graft material is not normal bone and is being linked to implant failure, irrespective if the material is synthetic or cadaver.
- A biocompatible barrier is necessary to separate the mineralizing compartment from the non-mineralizing compartment in order to achieve this level of success.
- Granulation tissue removal is required. When a buccal dehiscence is present, the granulation tissue is embedded into the buccal flap. This granulation tissue cannot be scraped off as with bone. The granulation tissue on the buccal flap must be surgically removed.
- A resorbable granular graft material must be used in order to maintain volume. The granules must only be resorbed by osteoclasts so as to maintain volume until the granules are surrounded by bone. When the granules are no longed needed to maintain volume, they are resorbed and completely removed to produce normal bone.
- The implant can be placed in a graft site that contains unresorbed graft material because rapid resorption does not occur until the implant is loaded and remodeling occurs.
- If the bone does not look normal, it is not normal and a different graft material should be used. Newly regenerated healthy normal bone is always white in color and may contain some yet to resorbed granules. If the bone is not white, you should not be placing an implant into the site.
Socket grafting is becoming one of the most complex bone grafting procedures dentists perform and the more knowledge we acquire, the higher the success rates for our implants. The following case presented several challenges that required on-the-spot decisions to achieve long term success of the bone graft and implant: Please review the following case below:
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