To Socket Graft or Not to Socket Graft

Slide 1:

Anthony J Reganato, DDS, MS Private Practice Periodontist West Suburbs-Chicago, IL “The Reganato Lecture Series” Sponsored by Woodlake Family Dental of Naperville, IL To socket graft or not to socket graft, that is the question

Bone Loss after Extraction:

Bone Loss after Extraction In 1960, Amler reported the human alveolar socket healing sequela in undisturbed extractions. Mineralization is apparent at day 18, but by 38 days, the lamina dura had lost its definitive outline. At this stage the alveolar crest appears to undergo a slight resorption, which progressively increases. The bone fill that occurs in extraction sites falls short of the original crestal height and width and continues to degrade over time.

Prevention of Bone Loss:

Prevention of Bone Loss Misch et al: " During the first year after tooth loss, 40 - 60% of the width of the alveolar ridge resorbs after tooth extraction " The resorption and collapse of the hard and soft tissue architecture increases the complexity of the restorative treatment plan for the doctor and has a dramatic negative effect on the esthetics of the final prosthesis. To prevent this complication, grafting extraction sockets with alloplastic materials has become a routine part of extraction surgery in many offices.

Socket Grafting Rationale:

Socket Grafting Rationale Pietrokovskia and Massler (University of Illinois) studied the morphologic changes that take place after a tooth is extracted and the upward plus inward resorption pattern of the alveolar maxilla. This resorption process can make the commitment of a natural-looking restoration for our patients more difficult to achieve Many of us do not realize the necessity for grafting fresh extraction sockets for preservation of the alveolar process. Maintenance of the ridge form is of utmost importance if esthetics dictate the degree of satisfaction for the patient.

When Socket Grafting is NOT a Necessity:

When Socket Grafting is NOT a Necessity Regeneration of the extraction socket restores complete morphology and bone volume to the residual ridge. This most often occurs independent of a graft material when there are 5 bony walls more than 1.5 mm thick around an atraumatic extraction site. This clinical condition is found most often in the posterior mandible and maxillary molar regions, particularly in patients with thick periodontiums . For example, a mandibular third molar extraction site usually has thick lateral walls of bone, and most often the bone area is regenerated in both height and width, with no graft material or regeneration technique in the sockets.

When Socket Grafting is NOT a Necessity:

When Socket Grafting is NOT a Necessity The extraction process of a tooth provides many of the keys necessary to grow bone in the socket under these surrounding bone conditions. The surgical insult sets up a Regional Acceleratory Phenomenon for healing (which increases the rate of repair and adds bone morphogenetic protein to the site) The 5 bony walls of the extraction socket protect the graft from mobility The torn blood vessels in the periodontal complex leak growth factors into the region (including platelet derived growth factor and transforming growth factor) The space for the bone regeneration process is maintained for several months because of the 5 surrounding walls of the bone The bony walls provide blood vessels coming from bone into the regeneration site (which bring in osteoblasts for bone formation), and the defect size is small ( ie , one tooth).

When Socket Grafting is NOT a Necessity:

When Socket Grafting is NOT a Necessity The only initial key element missing for successful bone regeneration is soft tissue closure over the extraction site The surrounding epithelium around the tooth extraction site begins to grow over the blood clot and granulation tissue of the socket, and within 3 to 4 weeks covers the site. To aid in this process, a piece of collagen may be placed within the socket and several sutures placed over the extraction socket to prevent dislodgement during initial healing The extraction site often forms bone under these ideal conditions with very little loss of bone volume width or height ( Misch article)

QUESTION:

QUESTION STATEMENT: The extraction site often forms bone under these ideal conditions with very little loss of bone volume width or height . QUESTION: In the posterior mandible and maxilla where bone height may already be compromised due to the position of the inferior alveolar canal and the maxillary sinus, respectively, would this “very little loss of bone volume width or height” bear any clinical significance when planning for an implant? YES

When Socket Grafting IS a Necessity:

When Socket Grafting IS a Necessity Clinical significance: if this “very little loss of bone volume width or height” is the deciding factor between an implant of less than 10mm in length and an implant of 10mm or more in length, socket grafting is necessary to preserve the existing bone volume Numerous studies have shown that implants less than 10mm in length have diminished survival and success rates compared to implants of 10mm in length or greater

When Socket Grafting IS a Necessity:

When Socket Grafting IS a Necessity When a lateral plate around a socket is less than 1.5 mm thick , or is partially to completely missing , the following events occur: The resorption and/or absence of the bony wall prevents space maintenance, reduces host bone vascularization , and replaces it with soft tissue invagination . Unfortunately, this condition is most often observed in the anterior regions of the jaws, especially in the premaxilla

When Socket Grafting IS a Necessity:

When Socket Grafting IS a Necessity Sockets with a missing lateral wall are significantly compromised, and heal by repair rather than regeneration. Bone will not grow above the lateral plate bone level of the extraction site during the repair process without a bone grafting procedure. In addition, when the labial plate of bone is thin or absent, bone resorption in width occurs. For example, the maxillary anterior region may be reduced more than 23% within the first 6 months after an extraction.

When Socket Grafting IS a Necessity:

When Socket Grafting IS a Necessity When conditions of repair instead of regeneration are present, socket grafting for ridge augmentation at the time of extraction is indicated. Tooth extraction without grafting under these conditions results in a decreased residual bone volume as a result of inadequate host conditions and further resorption of the thin bony wall at the site. As a consequence, one of the first determinations after the tooth extraction process is the assessment of the thickness of labial and palatal plates of bone and their relative height to the ideal volume desired. When one of the lateral plates of bone is thinner than 1.5 mm , or additional height is desired , a socket graft is indicated (even in the presence of 5 bony walls).

Extraction without Grafting:

Extraction without Grafting EXAMPLE OF AN EXTRACTION PERFORMED SEVERAL MONTHS AGO WITHOUT GRAFTING

Extraction without Grafting:

Extraction without Grafting HMMMM…

Implant Placement without Previous Grafting:

Implant Placement without Previous Grafting SOCKET GRAFTING THAT ISN’TPERFORMED NOW WILL COME BACK TO BITE YOU IN THE FUTURE…AND MAY LEAD TO GRAFTING ANYWAY

Indications for Socket Grafting:

Indications for Socket Grafting INTACT LABIAL PLATE LESS THEN 1.5MM THICK DIMINISHED BONE WIDTH IN ADJACENT AREA REQUIRES GBR*

Indications for Socket Grafting:

Indications for Socket Grafting INTACT BUCCAL PLATE LESS THEN 1.5MM THICK DIMINISHED BONE WIDTH IN ADJACENT AREA REQUIRES GBR*

Indications for GBR:

Indications for GBR ABSENCE OF BUCCAL PLATE REQUIRES GBR* GBR: BONE GRAFTING WITH MEMBRANE INSIDE BUCCAL FLAP

Indications for GBR:

Indications for GBR EXTREMELY THIN BUCCAL PLATE WITH DEHISCENCE/FENESTRATION REQUIRES GBR*

Case Report: Socket Grafting:

Case Report: Socket Grafting

Case Report:

Case Report

Case Report:

Case Report

Case Report:

Case Report

Case Report:

Case Report

Case Report:

Case Report

Learning Case:

Learning Case

Slide 30:

ATRAUMATIC EXTRACTIONS MINIMIZE NEED FOR FLAP ELEVATION SOCKET GRAFTING PERFORMED TO PRESERVE BONE VOLUME EDENTULOUS SITE ALLOWS FOR PRIMARY CLOSURE WITH PEDICLE FLAPS NOTE: PONTIC SPACE WHERE #12/13 HAVE BEEN MISSING WITHOUT PREVIOUS GRAFTING

Slide 31:

BONEVOLUME PRESERVATION WHERE SOCKET GRAFTING PERFORMED SEVERELY DIMINISHED BONE WIDTH IN AREA WHERE TEETH WERE MISSING IMPLANTS PLANNED FOR #11, 13, 14 SITES NOW WHAT DO WE DO??? GBR

Implant Placement :

Implant Placement

Conclusion:

Conclusion Proper diagnosis in the treatment planning phase is critical in order to render the appropriate treatment modalities Critically evaluate all intra-surgical factors when performing socket grafting Always consider the hard AND soft tissue in sites where implants are planned Staging of treatment may be necessary in order to arrive at the ideal result

Case Report: Combo Therapy :

Case Report: Combo Therapy

Case Report: Combo Therapy :

Case Report: Combo Therapy

Case Report: Combo Therapy :

Case Report: Combo Therapy

Case Report: Combo Therapy :

Case Report: Combo Therapy

Case Report: Combo Therapy :

Case Report: Combo Therapy

THANK YOU:

THANK YOU CARNIVORE CHALLENGE “The Reganato Lecture Series” Sponsored by Woodlake Family Dental of Naperville, IL