postextraction alveolar ridge preservation_ biological basis and treatments

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25.01.2013 Postextraction Alveolar Ridge Preservation: Biological Basis and Treatments

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InternationalJournalofDentistryVolume2012(2012),ArticleID151030,13pagesdoi:10.1155/2012/151030

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PostextractionAlveolarRidgePreservation:BiologicalBasisandTreatments

GiorgioPagni,1GaiaPellegrini ,1WilliamV.Giannobile,2,3andGiulioRasperini1

1UnitofPeriodontology,DepartmentofBiomedical,SurgicalandDentalSciences,UniversityofMilan,FoundationIRCCSCGranda,20142Milan,Italy2DepartmentofPeriodonticsandOralMedicineandMichiganCenterforOralHealthResearch,AnnArbor,

MI,USA3DepartmentofBiomedicalEngineering,CollegeofEngineering,UniversityofMichigan,AnnArbor,MI,USA

Received15February2012;Accepted2April2012

AcademicEditor:FigenCizmeciSenel

Copyright2012GiorgioPagnietal.Thisisanopenaccess articledistributedundertheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract

Followingtoothextraction,thealveolarridgeundergoesaninevitableremodelingprocessthatinfluencesimplanttherapyof theedentulouarea.Socketgraftingisacommonlyadoptedtherapyforthepreservationofalveolarbonestructuresincombinationornotwithimmediatimplantplacementalthoughthebiological baseslyingbehind thistreatmentmodalityarenot fullyunderstoodandoftenmisinterpretedThis review is intended to clarifythe literature support tosocketgrafting inorder toprovide practitionerswith valid tools tomakeconsciousdecisionofwhenandwhytorecommendthistherapy.

1.Introduction

Anatomicalchangesandphysiologicalprocessestakingovertoothextractionwerestudiedinthepast[13];however,sincetheintroductionofdentalimplantsinmodernodontology,theseissuesandthepreventionofedentulousjawatrophyhavebecomeveryhottopics.Thsurvival of implants and theirability toprovide adequate functionand esthetic arestrictlycorrelatedwith their properpositioning inrelationtothealveolarhousing,theneighboringteethandtheoccludingdentition.Itisthuseasilyunderstoodthetremendouseffortthathas beenused bymany researchers and practitioners in reducing thisunavoidablemodelingand remodelingprocess. Thisarticlegoethroughthebiologicalbasisforsocketaugmentationprocedureandtheavailabletreatmentoptionstopreventedentulousridgeatrophy.

2.AlveolarRidgeRemodeling

Maxillary andmandibular bony complexes are composed by several anatomical structures with a proper function, composition, andphysiology:(i) basalbonethatdevelopstogetherwiththeoverallskeleton,andformsthebodyofmandibleandmaxilla;(ii)alveolarprocesthatdevelopsfollowingtootheruptionandcontainsthetoothalveolus;(iii)thebundlebonethatlinesthealveolarsocket,extendscoronallyforming the crestof thebuccalbone,andmakespartof theperiodontalstructureas itencloses the external terminationsof periodontafibres(Sharpeysfibers).

After tooth extraction, bundle bone appears to be the first bone tobe absorbed [46] whereas alveolar bone is gradually absorbedthroughoutlife[7,8].Theremodelingprocessresultsinaridgemorphologyreducedinverticalheightandmorepalatalinrelationtotheoriginaltoothposition[13,9].

Studiesfromanotherresearchgroupsuggestbone resorptiontooccur in2 phases (seeFigure 1).Duringthefirstphase,bundleboneisrapidlyresorbedandreplacedwithwovenboneleadingtoagreatreductioninboneheightespeciallyinthebuccalaspectofthesocket,asitcrestalportioniscomprisedsolelyofbundlebone[ 10].Thebuccalplateexperiencesmoreresorptionevenbecauseitisgenerallythinner

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averaging0.8mminanteriorteethand1.1mminpremolarsites[11].In-vitroanimalstudieshavedemonstratedtheosteogenicpotentialoPDL-derivedcells[12,13]althoughtheroleofbundleboneinprovidingcellsfortheregenerationofnewbonehasbeenmorerecentlychallenged[14]asnewboneformationappearstoinitiatefromthesurroundingalveolarbonecells[46].Thisgroup reported that thpresenceorabsenceofPDLintheextractionsocketdoesnotinfluencethefeaturesofhealingafter3months[15].Duringthesecondphasethe outer surface of the alveolar bone is remodeled causing an overall horizontal and vertical tissue contraction. The reason for thiremodelingprocessisstillnotwellunderstood.Disuseatrophy,decreasedbloodsupply,andlocalizedinflammationmightplayimportantroles in bone resorption. However,i t isnowapparent thatbone remodelingisa complexprocess involving structural, functional,andphysiologicfactorsandthatsurgicaltraumafromextractioninducesmicrotraumatosurroundingbone,whichacceleratesboneremodelin[16].

Figure1:Healingoftheextractionsocketwithandwithoutsocketgrafting.Whensocketgraftingisnotadopted,majoralveolarridge resorptionoccurs.Ina firstphase,initiallythebloodclot, subsequentlythegranulationtissueandlatertheprovisional matrixand thewovenbonefill upthe alveolus. Thebundle bone is completelyresorbed causingareduction inthevertical ridge. Ina second phase, thebuccalwall and thewoven bone are remodeledcausing thehorizontal and further vertical ridge reduction. Whensocket grafting is adopted, the first phase and vertical bonereductionstilloccur,however,thesecondphaseandthehorizontalcontractionarereduced.

Resorptionrateofthealveolarridgesisfasterduringthefirstsixmonthsfollowingtheextraction[9,17]andproceedsatanaverageof0.51.0%peryearfortheentirelife[7,8].Theheightofahealedsocketneverreachesthecoronallevelofboneattachedtotheextractedtoothandhorizontalresorptionseemstobegreaterin themolar regioncompared tothepremolar area [18,19].Schroppetal.estimatedtwothirdsofthehard andsofttissuechangesoccurin thefirst3months.Theauthorsreported50%ofcrestalwidthtobe lostina12-monthperiod(correspondingto6.1mm;range2.7to12.2mm),2/3ofwhich(3.8mm;30%)occurredinthefirst12weeks.Whenexaminingthepremolarareaonly,alossof alveolarridgewidthof 4.9mm(45%)wasreported,ofwhich3.1mm(28.4%)occurredinthefirst12week

[20].Arecentlypublishedsystematicreview[21] reportedagreaterhorizontal alveolarridge reduction(2963%;3.79mm)thanverticaboneloss(1122%;1.24mmonthebuccal,0.84mmonmesial,and0.80ondistalsites)at6months.Inalong-termstudy,Ashmanreportedanalveolarboneshrinkageof4060%inheightandwidthwithinthefirst2-3years[8,22].

3.SocketHealing

Immediatelyaftertoothextraction,thealveolarsocketisfilledbybloodclotthatisreplacedbygranulationtissuewithin1week(seeFigur1)[23].Inthehealingofaskinwound,epithelialcellsmigrateunderneathandareprotectedbythebloodclot.Insockethealinginstead,thepithelium migrates over the granulation tissue to cover the healing socket [24]. This happens because this inflammatory tissue irecognizedasaconnective tissueby theepithelial cells,therefore, cellularmigrationoccursover itssurface.This is importantwhenwexamineguidedboneregenerationappliedtosocketgrafting.Startingfromtheapicalandlateralresidualbonywalls,thegranulationtissueisrapidlyremodeledtoprovisionalmatrix.Mineralizingprocessesoccurleadingtotheformationofwovenbonethateventuallyisreplacedbymaturelamellarbone[25].Formoreinformationonsockethealingstages,pleaserefertoTable 1.

Table1:Healingof theextraction socket.Articles reporting timing and histological evidence of extraction sockethealingeventsarereported.

Earlyhumanhistologicalinvestigationsreportedthatextractionsocketsarefilledwithdelicatecancellousboneintheirapicaltwothirdsa10 weeks, and they are completely filled with bone at 15 weeks [24]. Increased radiopacity is demonstrated as soon as 38 days andradiopacitysimilar tothatof thesurroundingboneat105days[24].These figuresmight bepartiallybiasedasspecimenswereharvestedfromcadavers;thereforetheirlateageandtheirsystemicconditionmighthaveledtodelayedwoundhealingcapabilities.Ontheothersideanimalstudiesdemonstrateacceleratedhealingas3weeksoldextractionsocketsinhumanscomparewith9-10daysoldsocketsindogsanda3.5monthssocketsinhumanscompareswith8weekssocketsindogs[26].

4.RationaleforExtractionSocketPreservation

Boneformationinthealveolarsocketisanaturallyoccurringeventaslongassurroundingalveolarwallsremainintact;however,thealveolarridgevolumetriccontractionmayimpairimplantplacement.

Toreduceloss of alveolarbone to acceptablelevels, several surgicaltechniqueshave beenproposed.Reducing theextractiontraumaandlimiting flap elevation [31] are essential for obtaining success in each of these procedures. Animal studies show mixed results whenevaluatingdifferencesinridgeremodelingbetweenflappedandnonflappedextractionsockets[ 3136]althoughit hasbeenhypothesizedthatbydisruptingthethinlayerofcellsthatcomprisestheosteogeniclayeroftheadultperiosteum,theelevationofaflapmightdiminishthe ability ofperiosteal cells to regeneratebone, whileanundisturbedperiosteummaintains its osteogenicpotential [10, 3739]. It ipossible that flap elevation affects alveolar dimensional alterations only in the short-term [21],while in the long term no appreciabldifferencesarefound[ 36].Inguidedboneregeneration4,methodscanbeusedtoincreasetherateofboneformationandtoaugmentbonvolume:osteoinductionby theuseofappropriategrowthfactors;osteoconduction,whereagraftingmaterialservesasa scaffoldfornewbonegrowth;distractionosteogenesis,bywhichafracture is surgicallyinducedandbonefragmentsarethenslowlypulledapart;finallyguidedtissueregeneration,whichallowsspacesmaintainedbybarriermembranestobefilledwithnewbone[40].Utilizingtheseconcepts
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ithasbeenproposedguidedboneregenerationwithnonresorbableandabsorbablemembranes,severaltypesofbonegraftswithorwithouuseofbarriermembranesortheadditionofmucogingivaltreatments,andmorerecentlytheuseofbioactivemoleculesforthegenerationobonein the extractionsocket.Whenanalyzing the results of the following describedstudies,it shouldbe keptinmindthe goalof thadditionalservicethatisprovidedtothepatient,whichincludethefollowing:

Inthefollowingsections,severalarticlesattemptingtoobtainthesepurposesbymeansofalveolarridgepreservationwillbereviewedandbrieflysummarized.

4.1.RidgePreservationwithMembranes

Guided boneregeneration(GBR) techniques utilize barriermembranes to refrain gingival cellsfrom penetrating into thedefect to bregenerated.TheconceptofcompartmentalizationwasintroducedbyMelcher[ 39]toexplainperiodontalwoundhealing,butitmaynotbapplicabletosockethealing.Ifitwere,onewouldexpectthesockettobefilledwithsofttissueinallinstances.Ontheotherside,evenearlyobservationsinhumansandanimalsdemonstratedthatthealveolarsockettendstohealbyregenerationofboneuptothealveolarcrest.Ainperiodontalwoundhealing[4143],thestabilityofthebloodclotpreviouslydescribedexplainswhythecompartmentalizationconceptdoesnot result in asocket filledby epitheliumand howepithelialcellsmigrateover the granulation tissueto close the healingsocketQuestionsremainastowhetherbarriermembraneshaveaneffectinmaintainingalveolarridgemorphology.

In 1997, Lekovic and coworkers adopted nonabsorbableePTFE membranes for the preservation of the alveolar ridge following toothextraction.Nochangesinclinicalmeasureswerenotedinthetestsitesthatremainedprotectedfor6monthswhilesignificantvolumetricchangeswereobservedincontrolsitesandintestsitesexperiencingmembraneexposure[44].Pinhoandcoworkersevaluatedtheuseofatitaniummembranewithorwithoutautologousbonegraft.Theyfoundnosignificantdifferencesbetweengroupsand,therefore,concludedthatspacemaintenanceismoreimportantthantheuseofgraftingmaterialsinthetreatmentofextractionsockets[ 45].

Barriermembranesseemtominimizealveolarboneresorptionwhencomparedtononintact(released)periosteumregardlessoftheuseoadditional grafting material. Titaniummembranes certainlywouldhave adistinctly different mechanism of action when compared toresorbablemembranes thaton theotherside reducethepotential ofexposure anddonot requireasecond surgicalintervention fortheiremoval. In1998,Lekovicetal.examined the effectofglycolideand lactidepolymermembranesdemonstratingreducedlossofalveolaheight,moreinternalbonesocketbonefillandlesshorizontalresorptionthancontrols[46].Luczyszynetal.evaluatedtheeffectofacelluladermal matrixwith orwithout aresorbable hydroxylapatite graft.Both groups preservedridge thickness, although, betterresultswerachievedinthecombinedtreatmentgroupsuggestingthatbonegraftsmightbenefitboneregenerationwhenusingaresorbablemembrane[47].

Arecentstudyperformedadetailedevaluationofthehealingofextractionsocketscoveredwitharesorbablecollagenmembrane.Throughtheuseofhistologicalevaluation,subtractionradiography,andof-CTanalysis,thisstudydemonstratedthatadequateboneformationfoimplantplacementoccursasearlyas12weeksfollowingtoothextraction,withinsignificantchangesinalveolarridgedimensions[48].

4.2.RidgePreservationwithBoneGraftsandBoneSubstitutes

Theclinicaladvantagesofbonefillersinalveolarridgevolumepreservationandpreventionofadditionalbonegraftingprocedurearelargelysupportedbytheavailableliterature[47,4951].Minimalridgeremodelinghasbeenobservedwhenusingnonresorbablehydroxyapatitecrystalscoveredbyarotatedpediculatedsplitthicknesspalatalflap[52],DFDBAcoveredwithanePTFEmembrane[53],orevenallogenicorxenogenic bone grafts coveredwith nothing but a collagen plug [51, 54] (Figure 1). Histological evidence demonstrates that bonformationoccursoverthesurfaceoftheimplantedosteoconductivegraftparticles[ 55,56].At 3monthsorlater,graftedsocketsgenerallydemonstratehighermineralized tissuefigures,whenconsidering bothnew vitalbone andremaining graftparticles,butthe formationonewboneappearstobesimilaringraftedandnongraftedsites.Itcanbeextrapolatedthatresidualparticlesoccupypartofthevolumethawouldhavebeenoccupiedbybonemarrowifbonegraftingwerenotadopted[57].

At earlierhealing stages (2weeks) instead, grafted sockets demonstrate xenograft particles enclosed in connective tissue andcoated bymultinucleated cellswhennongrafted sitesalreadyshownewly formedwoven bone occupyingmostof the socket[58].Thisresponseitypical ofa foreignbody reactionwhich canbe elicitedby the xenograftand though it is clinically non-immunogenic,non-toxic andchemicallyinert[59],it resultsinadelayedhealingresponseduringtheearlieststagesofsockethealing.Manyarticlesreportedonlyapartiaresorptionofthegraftedparticlesatshortandlongtimepoints[49,53,58,6063]arisingdoubtsontheachievementoftheosteointegratioof implants inserted inaugmentedsites andonthe successof the restorative therapy.Histological animal studies[64, 65] evaluated thosteointegration ofdental implants following boneregeneration performed with different bone fillersand observeda bone-to-implancontactsimilartothatofimplantsplacedinpristinebone(40%to65%).Furthermore,clinicalstudiesobservedthatgoodprimarystabilitycanbereachedatimplantinsertion,thatthegraftingproceduredoesnotimpairearlyosteointegration[66,67],andthatimplantsplacedinboneregeneratedusingmineralizedgraftsareabletosustainloadingandprovidesimilarlong-termresultsasthoseplacedinpristinebon[68].

Mineralizedgraftingmaterialsmayinterferewiththeearlieststagesofsockethealingandtheireliminationmayrequireseveralyears[57]o

(i)(ii)(iii)(iv)(v)(vi)

toenableinstallationandstabilityofadentalimplant,toreducelossofalveolarbonevolume,toreduceneedforadditionalbonegraftingprocedures,toenablethegeneratedtissuestoprovideimplantosseointegration,toimprovetheestheticoutcomeofthefinalprosthesis,toregeneratebonefasterallowingearlierimplantationandrestoration.
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theymayinfactbenonresorbableeveninthelongterm[62].Ontheotherside,theirabilitytopreventcrestalridgeresorptionandsustainlong-termimplantsuccesshasbeenclearlydemonstrated[ 6668].

Otheradvantagesintheuseofosteoconductivegraftingmaterialwerereportedbyaclinicalandhistologicalhumanstudyofpostextractivdefectsinposteriormaxillaryareatreatedwithaxenogenicgraft.Inthisstudy,Rasperinietal.confirmedthespace-maintainingactivityotheimplantedmaterialandreportedadecreaseddemandforsinusliftaugmentationprocedurewhenthesocketpreservationprocedurewaperformed[63].Throughacomputedtomographyanalysisofmaxillaryanteriorpostextractivedefects,Nevins etal.reportedthat79%ografted sitesunderwent lessthan 20%buccalplateloss,while71%of nongraftedsitesdemonstratedmorethan20%buccalplateloss.Aninterestingfindingofthisinvestigationwasthateventheexperiencedsurgeonsparticipatingtothisstudywerenotabletopredictthefateothebuccalplate,therefore,theauthorssuggestedsocketgraftingtobeperformedatthetimeofextraction[ 69].

4.2.1.BuccalBoneOverbuilding

Anothertechniquethatmaybeadoptedistoaugmentthebuccalbonebyimplantinggraftmaterialsonitsbuccalsurface.Simonetal.usedDFDBAcoveredbyabioabsorbablemembranefortheaugmentationprocedure.Thedimensionsontheridgewereaugmentedcomparedtothe originalvolume butthe invasivenessandtechnical demandof thisprocedure mayrefrainthe clinicianfrom itsuse ineverydaypractice[70].Inanotherstudy,2differentgraftingtechniqueswereadoptedaccordingtowhetherthebuccalbonewasintactordehiscenceSocketswithanintactbuccalboneweregraftedtothelevelofthealveolarcrest,amembranewasusedtoprotectthedefect,andtheflapwaclosed by primary intention while sockets with deficient buccal bone were augmented. Their results showed complete loss of thhorizontallyaugmentedboneinaugmentedsites,butgraftedsitedexperiencedbonelossinagreaterextentthanaugmentedsites[ 71].

Anhistologicalanimalstudyfoundthatbuccalboneaugmentationwithaxenograftfailedtopreventthephysiologicalbonemodelingandremodelingtakingpartinthebuccalandlingualbonywalls;however,theinsertionof graftingmaterialseemedto promotedenovohardtissueformation,thuslimitingthetotalbonevolumecontraction[57].Xenograftparticlespositionedonthebuccalsurfaceoftheextractionalveoluswerefoundtobeencapsulatedincollagenfibersafter3monthsofhealing.Theywerealwayslocatedlateraltotheperiosteumofth

buccalwalland,therefore,didnotparticipatetoridgeaugmentation[57].Ficklandcoworkersalsoproposedtheoverbuildingofthebuccabonewithaxenograftandamembrane.Datafromtheirstudies indicatesthatextrasocketgraftingdoesnotseemto compensateforridgalterationafterextractionpossiblybecauseoftheadditionaltraumatobuccaltissues[72,73].

4.2.2.FreeSoft-TissueGraftsoverGraftedSockets

Theplacement of free soft-tissue graft to cover the augmented alveolar socket was introduced to minimize the soft tissue shrinkageoptimize aestheticalresultsofimplant restoration,andobtaina primaryclosurethatmay preservethegraftfrombacterialinfections andsecondary graft failure [74, 75]. The first attempt to cover the socket graftwith an autogenous soft tissue implantwas described byLandsbergandBichachoin1994[76].NevinsandMellonigsuggestedtheuseofsofttissuegraftstoimproveridgetopographyaftertoothextraction[77]andincombinationwithimmediateimplantplacement[78].

In1999,Taldescribedthesurvivalof circularconnectivetissuegraftsplacedoverextractionsocketstreatedeitherwithDFDBAorBio-OssTheyfoundthatthesurvivalwasnotdependentontheadoptedgraftandthatat1week18/42graftswerevital,13/42werepartiallyvital,and11/42werenonvital.Completeclosureofallsocketsoccurred4weekspostextraction.Theauthorsnotedthatmoreoftenpartiallyvitalgraft

maintainedtheirvitalityoverthesocketareamorethanonthegraftmargins;theyconcludedthatthenourishmentcouldbeoriginatedfromplasmaticelementsinthesocketbloodclotmorethanfromvesselsoriginatingfromtheperipheryofthegraft[79].

4.3.ImmediateImplantPlacementandtheJumpingDistance.

The first report ofimplantplacement immediatelyaftertoothextractiondatesback to1978when theTbingenimmediateimplantwadescribed[8082].In1991,Barzilayetal.suggestedthatimmediateimplantplacementmightreduceoreliminatealveolarridgeresorptionduring the initial healingof the alveolar extractionsocket [83]. In two subsequent papers in amonkeymodel, he demonstrated thasubstantiallylessridgeremodelingwasinducedintheimmediateimplantgroup[ 84]andthathistologicallybonetoimplant contactwasimilarwithinthedifferentanatomicregionsoftheoralcavity[85].

OtherauthorschallengedtheresultsoftheCanadianreportingthattheplacementofanimplantinthefreshextractionsitefailedtopreventhe remodelingthat occurred in thewallsof thesocket.Theheightofthebuccal andlingualwallsat3monthswas similarcompared toextractiononlysites[8690].Verticalbonelosswasmorepronouncedatthebuccalaspectevenwithsomemarginallossofosseointegration[87].Histologically, thegapbetweentheimplant andthesocketwallsfilledinat4 weekswithwovenbone,while, thebuccal andlinguawallsunderwentmarkedsurfaceresorption.After12weeks,thebuccalcrestwaslocated>2 mmapicaloftheimplantmargin[88](Figure2)Evaluatingimmediatelyplacedimplants,Schroppetal.reported70%ofthe3-wallinfrabonydefectswithaparallelwidthofupto5 mm,depth ofmaximum4mm,and aperpendicular widthofmaximum2 mmhada capacityof spontaneoushealingwithina period of 3months[18]. Botticelli et al. found that11.25mm wideand 5mmdeep defectsaround implantshealed uneventfullywith orwithoumembrane[91].Defectsupto2.25mmwidewerefoundtohealusingbarriermembranes,althoughwhenthebuccalbonewasintentionallyremoved,lessregenerationatthebuccalaspectswasobserved[92].Thesestudiesadoptedananimalmodelwithsurgicallycreateddefectswhichtypicallyexhibitlesserresorptionthanextractionsockets[90].
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Figure2:Healingof theextractionsocket,with postextractive implantplacement,withandwithoutsocketgrafting.Aftertoothextractionandimmediateimplantplacement,thebloodclotfillstheremainingspaceandthebundleboneundergoesthephysiologicalchanges.Whengraftingmaterialisplacedaroundtheimplantsurface,fillingtheremainingsocketarea,thebuccalbonewallremodelingprocessiscorrupted,thusleadingthemaintenanceofthehorizontalridgevolume.

When immediateimplantplacement isadopted,manycliniciansfeeltheneedof filling thebuccal gap (i)by placingalargerdiameteimplant,(ii)byplacingtheimplantinamorebuccalposition,or(iii)bygraftingthebuccaldefectwithsomekindofbonesubstitutesGiven theavailableliterature,the firsttwo strategiesdonotseemtoberecommendable. Itseemsinsteadthatthepresenceofalarge gap

betweenthebuccalwallandtheimplantapparentlypromotesnewboneformationandenhancesthelevelofbone-to-implantcontact[ 88].

An implant position 0.8mmdeeper andmore lingual in relation to the center of the socket results in a lesser degree of buccal bondehiscence[93].Otherstudiesdemonstratedthattheclosertheimplantisto thebuccalbonyplate,themorethe buccalboneresorbs[9495].Bone resorptionof the buccalcrestismorepronouncedwhenplacing large size(5mm) root-formed implantswhen compared tocylindricalimplantswithasmallerdiameter(3.3mm)demonstratingthatimplantsplacedimmediatelyaftertoothextractionfailtopreservthealveolarcrestofthe socketirrespectiveof theirdesign orconfiguration[96].Moreover,softtissuesfollowedbonelevelsand alsotheywerelocatedmoreapicalonlargesizeimplantscomparedtosmallersizeimplants[ 97].

Canevaetal.evaluatedtheuseofacollagenmembraneoverthebuccalgapofimmediatelyplacedimplantsandfoundthatthealveolarcresoutlinewasbettermaintainedatthetestsitescomparedwiththecontrolsitesevenifthebuccalgapwasrelativelysmall[ 98].Interestinglyenhancedbonepreservationwasfoundwhen usingdeproteinizedbovinebonemineral particlesand acollagenmembranecomparedtocontrolswhereasno suchbenefitwasnotedwhenusing magnesium-enrichedhydroxyapatite[99101]. RecentlyArajo and coworkerhaveevaluatedtheuseofBio-OssCollageninthevolumebetweenthebuccalwallandtheimplantincasestreatedwithimmediateimplan

placementin anexperimentalanimalmodel.Theauthorsfound thatthis treatmentmodified theprocessofhardtissuehealing,providedadditional amountsof hard tissue atthe entranceof the previous socket,improved the level ofmarginal bone-to-implantcontact, andpreventedsofttissuerecession[102](Figure2).

Implants immediatelyplacedinto freshextractionsocketsareclassifiedasType1 implants, earlyplacedimplants (48weeks) followingtoothextractionareType2implants,Type3implantsrepresentimplantsearlyplaced(1216weeks)inasocketwithpartialbonehealingandType4implantsaredelayedimplantsplacedinafullyhealededentuloussite(>6month)[ 103].Timingofimplantplacementisnotatopictobetreatedin thisreviewbut itmightbeofinterest tothereader thatbonegrafting inearlyplacedimplants(Type2-3)seemstoprovidebetterhardtissuedimensionsandwithlesspostoperativecomplicationsthanbonegraftingindelayedimplants(Type4)[104].

Whenevaluatingtheexpressionofosteogenesis-relatedgrowthfactors,Linetal.demonstratedapparenttissuematurationdelayedduringosseointegration, compared to extraction socket bone repair. The two healing models developed distinct features and triggeredcharacteristic coordinated expression and orchestration of transcription factors, growth factors, extracellular matrix molecules, andchemokines. These groundbreaking findings open new horizons to researchers, which might lead to a better understanding of th

cooperativemoleculardynamicsinalveolarbonehealing[105].4.4.RidgePreservationwithNonmineralizedGrafts

Serinoetal.evaluatedtheuseofabioabsorbablepolylactide-polyglycolideacidspongeasaridgepreservationgraftingmaterial.Thegraftingmaterialwas placed with no attempt to achieveprimary intention wound closure. 6months following the extractions, biopsies werharvested. Both test and control extractionsockets showedmature andwell-structured bone with no residual particles of the graftedmaterial.Clinicalmeasuresseemedtofavorthetestgroup[106].Inafollowingstudy,boththeregeneratedsitesandcontrolsresultedinthformationofahighlymineralizedandwell-structuredbonewiththe controlgroupshowingaslightlyminorpercentageofmineralizedbone and ahigherpresenceof connective tissue in the coronalportion of the biopsies.Particles of the graftedmaterial couldnotbidentifiedinanyofthebiopsies[107].

Graftingmaterials with high resorption rates allow for the formation of bonewith no residual graft particles at the time of implanplacementandloadingbuttheirabilitytosustainalveolarridgevolumeinthelongtermmightbeinferiortothatofmineralizedgrafts.

4.5.NovelTissueEngineeringApproachesInordertoovercomethelimitationsofroutinelyadoptedbiomaterialsasallografts,xenografts,andalloplastsintermsofpredictabilityandqualityofboneformationandabilitytosustainalveolarridgemorphologyover longperiodsof time,noveltissueengineering therapiehavebeendevelopedincludingthedeliveryofgrowthfactorsincorporatedincarriers,thestimulationoftheselectiveproductionofgrowthfactorsusinggenetherapy,andthedeliveryofexpandedcellularconstructs.

Bonemorphogenicproteins(BMPs)areanexampleofgrowthfactors;theyhavetheabilityofinducingthedifferentiationofthehoststemcellsintoboneformingcellsinaprocessknownas osteoinduction[108].A feasibilitystudyintroducingtheuseofrhBMP-2absorbedincollagenspongefor alveolarridgepreservationaftertoothextractionwaspublished in1997.Howellet al.demonstratedthesafetyofthigraftingmaterial.Patients receiving socketgraftingdemonstrated increase inboneheightwhilepatientsreceiving aridgeaugmentationprocedure showed no evidence of augmented ridge width or height [109]. Implants placed in the regenerated bone were stable andpresentedhealthyperiimplanttissues[110].Afterthispilotstudy,Fioreliniandcoworkersperformedarandomizedclinicaltrialtestingthregenerative potential of the recombinant BMP-2 in the collagen sponge compared to the useof the collagen sponge alone.Anteriomaxillarypostextractionalveolardefectsinwhichmorethan50%ofthealveolarbuccalbonehadbeenlostpriortoextractionweretreated
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witheitherof the twograftingmaterial.Twodifferent rhBMP-2concentrationswereused(0.75mg/mL and1.50mg/mL).Significantlygreater augmentationwas noted in the 1.50mg/mL group and both rhBMP-2 groups outperformed the control groups. Histologicafindingsshowedgenerationofbonenodifferentfromnativebone[111].

PDGF-BBina-TCPcarrierisamaterialacceptedfromtheFDAforregenerationofboneandPDLelementsinguidedtissueregenerationprocedures.Nevinsetal. evaluatedtheuseof therecombinantprotein in socketgrafting. Inthis case,series8extraction socketsreceivedBio-OssCollagenhydratedwith0.3 mg/mLPDGF-BB,andflapswerereleasedforclosurebyprimaryintention.Then4or6monthsaftergraftingbonecore,biopsiesrevealedrobustboneformation.Also %newboneand residual graftingmaterialwerenoted at 4 months. However, % new bone and % residual grafting material were noted at 6 months in thehystomorphometricalevaluation[112].Morerecently,tissuerepair cells(TRC), acellconstructderived fromeachpatientsbonemarrowandcultivatedusingautomatedbioreactorstoconcentrationsnotachievablethroughasimplebonemarrowaspiration,wereevaluatedinsockethealing.Thisstudyshowedthatthiscellconstructisabletoproducesignificantconcentrationsofcytokinesandmaintainsthecellsability to differentiate toward both the mesenchymaland endothelial pathway andproduceangiogenic factors. TRC therapy enhancedformationof highly vascularmature bone asearlyas 6weeksafter implantationwhen compared toguided boneregeneration withnoseriousstudy-relatedadverseeventreportedandlowerdegreesofalveolarridgeresorptionwerenoted[113,114].Pleaserefertoourrecenreviewforfurtherinformationoncelltherapyapplicationsincraniofacialregeneration[115].

5.Conclusions

Postextractionalveolarridgeresorptionisaninevitableprocessandthemolarareaisnotanexception.Molarridgespresenthigherdegreeof resorptionthan premolarareas do.Socket grafting techniqueshave been readily adopted bydentists throughout the world.A greaamountofresearchhasbeenconductedtoexaminetheeffectivenessofseveralmaterialsormembranes.

Theuseof invasivetechniques ishardly recommendedat thistreatment timepointas anyprocedure requiringprimary intentionhealingwiththe advancementof flapsmay result in increased inflammatory response,in adecrease in vestibulardepth,and in the creationounaestheticscars.Evenexpertpractitionersmightnotbeableto accuratelydeterminewhenthesetechniquesmightbeindicated[69].Fotheverysamereason,lessinvasivegraftingtechniquesshouldbeadoptedwhenindicatedespeciallywhentreatingdefectsintheestheticormolarareas.Itshouldbeunderstoodthattheuseofosteoconductive-mineralizedgraftsdoesnotacceleratebonehealing,butmayallowfoabetterpreservationoftheridgevolumethatishighlydesirableforbothestheticandfunctionofthefutureimplantrestoration.Moreoveinvasiveproceduresasguidedboneregenerationandsinusfloorelevationarelessfrequentlyneededwhensocketgraftingisadopted[ 63]Formorepredictableresults,itisrecommendedtoallowpropertimeforbonehealingpriortoproceedwithimplantplacement.Anyway,whenimmediateimplantplacementisadopted,theuseofmineralizedgraftsonthebuccalgaphelpsreducingtheresorptionofthebuccalcrestbone[102]and maylessenthechances forundesirablehardand soft tissuerecessions.Clinicians shouldescape the temptationoplacinglargerdiameterimplantsorplacingtheimplantinamorebuccalpositioninordertofillthebuccalgap.Instead,alargergapshouldbepreservedandthebuccaldefectshouldbefilledwithbonesubstitutes.

Therationaleforafranklypalatal/lingualpositioningofimmediatelyplacedimplantsisalsosupportedbytheknowledgethatsignificantlymorefacialrecessionsarecorrelatedwithimplantsplacedtoobuccal[ 116,117].

Advancesintissue engineeringtechniquesmightsoonprovidepractitionerswithbiomaterials foramorepredictable andenhancedboneformationthatwill definitely improveourclinical results.Thesenovel biomaterials arecurrently evaluatedworldwide andwillsoonbeintroducedineverydaypractice.

Practitionersshouldbewellinformedofthebiologicalcharacteristicsofnewbiomaterialsandonwhichstagesofwoundhealingmaytheytakeanaction.

Thispaperattemptedtosummarizetheconceptsonsocketgraftingresultingfromtheavailableliterature.Currentknowledgemaystillbeinsufficienttofullyjustifytheuseofcertaintechniquesineverydaypractice,andmorestudiesevaluatingbasicbiologicalconceptsshouldbeperformed.

Insocketgraftingasinothermedicaldivisions,properdiagnosisisoftenmoreimportantthantherenderedtreatment.

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postextraction alveolar ridge preservation_ biological basis and treatments

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