Open Healing Socket Preservation with and without Implant restoration.

Can socket preservation be completed predictably without the additional surgical complications of flap creation, membrane application and tension-free closure?

Studies show socket grafting with biomaterials prevents atrophy.

Different biomaterials (autogenous, allogenic, synthetics, xenografts) and biological preparations (PRF, PRP, PRGF) are proposed to fill the extraction sockets with multiple protocols followed to achieve this.  Irrespective of origin, the processing of biomaterials affects their resorption characteristics which in turn impacts the level of bone regeneration and space maintenance achieved. A fully resorbing bone graft will generate more bone and is ideal when an implant is scheduled. A slow-resorbing biomaterial will favour volume preservation and is more suitable when an implant-supported restoration is not scheduled as it will be more resilient to natural remodelling and atrophy.  You can read more about this below and in our ‘tooth out what next’ article.

Conventional wisdom – primary closure

Conventional techniques for ridge preservation with socket grafting involve primary closure where a buccal full-thickness flap is raised and advanced to cover and protect the socket and dental membrane. Achieving primary closure prolongs surgical time and complexity, increases morbidity and delays healing.

Typical Dental Membranes are COLLAGEN which adds cost and complexity. Collagen membranes require complete tissue coverage because as a protein salivary enzymes will quickly dissolve them. Alternatives to collagen are POLYMER MEMBRANES such as PTFE or Powerbone Polymer membrane. PTFE will require a 2nd procedure for removal whereas Powerbone Polymer membrane adsorbs fully negating the removal procedure.

Aesthetic implications.

In addition, raising and advancing a flap to cover the extraction socket and create space to secure the dental membrane results in the disturbance of the vestibule buccally and the loss of the buccal keratinized soft tissues. This compromises aesthetic and functional results which may require additional surgical interventions to overcome.

Grafts for open healing socket preservation.

Particulate or granular grafts are mobile and require the protection and support of a barrier membrane with corresponding flap management compromises. (see below)

In the last decade, several bone grafting technologies have emerged that match the morphology of the site and offer self-stabilising features removing the need for a barrier membrane.

These technologies are differentiated by their format (Dental Putty, Cement, Socket Cone) and resorption profile (Full or partial).

The decision about the resorption profile of the bone graft chosen should be taken based on the restorative plan – IMPLANT YES or IMPLANT NO.

Both Powerbone Dental Putty and Biphasic Cone Graft are form stable and will not move around. For both, we recommend protecting the site with an Ora-Aid self-sealing dressing to encourage soft tissue healing by secondary intention. Ora-Aid can be held in place for a longer period with a cross suture slung over but not through the dressing. This is further described below.

Healing without Primary Closure.

Ridge preservation, the placement of a bone graft and maintenance of optimal aesthetics can be achieved successfully without primary closure.   The main advantage of not obtaining primary closure is an increased area of keratinized gingiva and stable mucogingival junction.

Numerous studies utilising form-stable calcium phosphate technologies show complete coverage by newly formed keratinized tissue at 12 weeks with maintenance of ridge volume and architecture. A flap is not advanced to cover the exposed graft in such cases. Instead, the site is protected topically to reduce graft loss in the first few days.

Graft Protection

Graft protection is especially critical in molar sites where the larger size of the socket requires a much longer time for soft tissue healing and complete coverage of the graft, compared to smaller anterior extraction sites.  A variety of materials are proposed to be suitable in such cases.

DENSE COLLAGEN SPONGE – A Parasorb cone can be compressed between the fingers and paced over the site to provide short-term sacrificial protection. Retention with a cross suture is recommended.

TITANIUM FOIL – Bionnovation titanium foil is an ultra-thin foil that is electro-chemically treated to make it suitable for exposed sites. The foil is easily trimmed to match the site. Retention is achieved with a cross-suture slung over and not through the foil. Removal does not require an access flap.

ORA-AID – Ora-Aid is a novel self-sealing film dressing that has applications as an external barrier for Open Healing Alveolar Ridge Preservation and protection of grafts and other materials placed inside the socket. Ora Aid is available in two sizes – 25 x 15mm and 50 x 15mm.

The key benefits of using the Ora-Aid are:

•  Self-sealing

When exposed to saliva and blood the Ora-Aid lower layer becomes adhesive whilst the upper layer creates a smooth protective surface due to the inclusion of a water-insoluble polymer with a mint flavour.

• Effective

Ora-Aid is easy to trim chairside, seals the wound from pathogens and accelerates healing. A simple cross suture prolongs protection.

Secure Suture or Tissue Adhesive

In all the above examples we recommend Polyglactin 910 or PGA adsorbing sutures as a sling over but not through the Ora-Aid. This type of suture adsorbs fully yet retains its function for the initial healing. Both can easily be placed. An alternative is to secure the site with tissue adhesive.

For further information – ask@regen-store.co.uk

Clinical images courtesy of Dr Minas Leventis (UK) and Dr Marcelo Faveri (Brazil)

References:

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• Fairbairn, et al. Alveolar Ridge Preservation Using a Novel Synthetic Grafting Material: A Case with Two-Year Follow-Up. Case Reports iN dentistry. Volume 2018 | Article ID 6412806
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