Preservation of the ridge and sealing of the socket with a combination epithelialised and subepithelial connective tissue graft for management of defects in the buccal bone before insertion of implants: a case series

Abstract

Defects in the layer of buccal bone lead to its loss after tooth extractions. This requires hard tissue grafting before implants can be put in place. The aim of this study was to evaluate the stability of hard tissue grafts inserted at the same time as the teeth were extracted. Teeth had to be extracted because of defects in the buccal bone. Extractions were combined with preservation of the ridge using autogenous and artificial bone. A combination epithelialised and subepithelial connective tissue graft was used to seal the socket. Wound healing was assessed and the width of the alveolar crest was measured after hard tissue grafting and during insertion of the implants. We studied 39 patients (20 female, 19 male, mean (SD) age 41 (7.9) years) who had 43 teeth extracted together with preservation of the ridge. One patient failed to attend for placement of the implant. Thirty-nine implants were inserted 5.3 (0.4) months after preservation of the ridge. Two patients developed partial necrosis of the combination graft, but in all other cases primary wound healing was uneventful. In three cases the bone grafts failed to consolidate. The mean (SD) width of the alveolar crest was after bone grafting 6.80 (1.20) mm and during insertion of implants 5.65 (1.50) mm; the mean resorption of the bone grafts was 1.2 (1.1) mm. We conclude that bone grafting to rebuild buccal alveolar defects at the same time that the tooth is extracted, combined with a soft tissue graft to seal the socket, showed promising results and could be an alternative treatment to delayed hard tissue grafting.

Introduction

Resorption of buccal soft and hard tissue is common after teeth have been extracted or lost, and makes insertion of implants in this aesthetically sensitive zone challenging.¹ Excessively thin buccal bone causes peri-implant recession, which is not easy to repair later.² Inadequate volume of bone was an absolute contraindication for implants in the late 1980s, but guided tissue regeneration as described by Buser et al. expanded the range of indications for implants.³

Delayed insertion of implants after loss of a tooth, which allowed for soft and hard tissue healing time of 3–4 months, was the preferred procedure.⁴ The size and shape of the bony defect dictated whether grafting and inserting an implant were done in one or two stages. Today numerous substitutes for bone are available,⁵ which work well for specific applications and defects. Autogenous bone for grafting is harvested from the vicinity, from the retromolar region, or from the chin.⁶ Soft tissue is enclosed primarily with coronal advancement flaps,⁷ but these displace the mucogingival junction with resulting impairment.

To prevent bony resorption within the first 3–4 months and to avoid major coronal advancement flaps, techniques to preserve the ridge, combined with sealing the socket after extraction of teeth with defects of the bony alveolar wall, have become the focus of interest.⁸ This permits minimally invasive grafting through the extraction socket without raising a flap.

It also prevents further loss of hard tissue, which has been the inevitable result.⁹

Sealing the grafted extraction socket and avoiding bacterial colonisation from saliva is essential. Free gingival grafts for sealing sockets were reported as early as 1994,¹⁰ but their failure rate was more than 50% (26% total necrosis, 31% partial necrosis),¹¹ so the use of combined epithelialised–subepithelial connective tissue grafts with a single or double pouch to seal the socket was introduced. These grafts were first described by Seibert and Louis for augmenting edentulous ridges designed to accommodate pontic areas.¹² Later these grafts with a single pouch were used to seal extraction sockets.¹³ Based on the experience of the single pouch, grafts with a double pouch were developed.¹³ The connective tissue portion(s) improve vascularisation and thicken the buccal soft tissue. This is important to achieve a natural profile. In addition, closure of the soft tissue of the extraction socket supports the adjacent papillas and prevents shrinkage of the locally attached gingiva.¹⁴

In this study we hypothesised that horizontal grafting of hard tissue at the same time as extraction of the tooth and primary closure of the wound with a combined epithelialised–subepithelial connective tissue graft would result in a predictable outcome, and it would be possible to insert the implants after the grafts had healed.