Post-extraction socket seal surgery with an epithelized connective tissue graft using a subpapillar tunneling procedure
P 0539
!
Jamal M. Stein1,2, Christian Hammächer2! 1Dept.
of Operative Dentistry, Periodontology and Preventive Dentistry, RWTH Aachen, Gerrmany; 2Private Practice, Aachen, Germany
1
Introduction
2
Materials and Methods
After tooth removal, alveolar bone resorption processes lead to dimensional changes of the alveolar ridge (Araújo & Lindhe 2005). In order to maintain the alveolar ridge contour, ridge preservation techniques have been proposed (Vignoletti et al. 2011). Although animal studies showed that biomaterials placed in extraction sockets might limit shrinking processes, they were not able to completely preserve the buccal bone wall (Fickl et al. 2008, Araújo et al. 2008). In order to improve the concept of ridge preservation, soft tissue grafts have been suggested to seal the alveolar socket and enhance the soft tissue prior to (Jung et al. 2004, Oghli & Steveling 2010) or simultaneously with (Landsberg 1997) implant placement. However, due to the limited blood support in a few of these techniques there is a risk of incomplete wound healing and necrosis (Tal et al. 1999). Combined epithelial connective tissue grafts have been used in order to improve blood supply and achieve a thickening of the buccal gingiva (Stimmelmayr et al. 2010). However, none of the previously reported socket seal techniques included the thickening of the interproximal papillae. The aim of the present prospective case series was to introduce a technique for post-extraction socket seal surgery using an epithelized connective tissue graft and socket filling with a xenogeneic graft and to analyze contour changes of the alveolar ridge.
13 patients (aged 29 to 59) requiring extraction of at least one maxillary anterior tooth were recruited for the present study. In all cases immediately after tooth extraction the following surgical procedure was applied (Fig. 1-5): Using microblades and tunneling knifes a subperiostal tunnel was prepared on the buccal side of the socket ranging towards the adjacent teeth and including the mobilization of both adjacent papillae. A combined epithelized connective tissue graft was harA
B
C
D
vested from the palate. Socket grafting was done using A
a xenogeneic bone graft imbedded in a 10% collagen matrix (BioOss Collagen, Geistlich). The connective tissue part of the graft was inserted on the buccal side of the socket and under the adjacent papillae, while the E
F
G
H
epithelized part was placed over the socket orifice and B
sutured at this position similar to a lid. Sutures were removed after 7 days. 5 months post-operative, patients were re-evaluated and implants have been inserted. Crown restoration was done another 5 months later. Fig. 2: Cross Section View
Fig. 1: Illustration of the socket seal surgery (A: Tunneling preparation; B: Undermining of the papillae; C,D: Harvesting of the graft; E-G: Insertion of the graft and socket fill; H: Sutures.
(A: Tunneling preparation; B: Graft in place)
Both the horizontal and vertical dimensions of the alveolar ridge were evaluated directly after extraction (a, baseline), directly after socket grafting (b) and five months later (c) before implant placement using a calliper (Castroviejo-Epker, Medicon) and periodontal probes (Goldman Fox/William, Hu-Friedy). Horizontal width was measured 1 mm apically from the extrapolated margin of the gingiva of the adjacent teeth on the buccal and palatal side. Vertical measurements included the position of the adjacent papillae and the midbuccal gingiva in relation to the incisal edge of the adjacent teeth.
3
Results
All 13 patients had been treated at 16 sites according the described surgical protocol and completed the follow-up period up to the final implant-supported crown restoration. No intra-operative or post-operative complications occurred. Five months post-operative, the mean reduction of the horizontal width of the alveolar ridge was limited to 0.5 mm, while the height of the mesial and distal papillae were moderately reduced by 0.2 mm and 0.4 mm, respectively. The buccal gingival margin of the alveolar ridge even showed a mean vertical gain of 0.5 mm (Table 1). A
B
F
C
G
D
E
H
I
Fig. 3: Socket seal surgery on 2 lateral incisors (A: Tunneling preparation; B: Papilla mobilization; C,D: Graft harvesting; E: Insertion of the graft; F: Socket fill; G: Sutures; H: 5 months postop.; I: Implants with healing abutments)
Table 1: Horizontal and vertical dimension changes Variable
A
A
B
B
Fig. 4: Case of Figure 3 (A: Baseline; B: Implants with provisional crowns)
Baseline
post-op.
5 months
Δ (Baseline - 5 months)
Horizontal width (mm) 8.7 ± 0.5 Distance incisal edge – tip of the mesial papilla (mm) 6.5 ± 0.8 Distance incisal edge – tip of the distal papilla (mm) 5.9 ± 0.8 Distance interincisal line - midbuccal gingiva (mm) 10.8 ± 0.8
9.5 ± 0.7 6.1 ± 0.8 5.5 ± 0.8 10.0 ± 0.9
8.2 ± 0.6 6.7 ± 0.8 6.3 ± 0.8 10.3 ± 0.8
- 0.5 ± 0.3 + 0.2 ± 0.8 + 0.4 ± 0.8 - 0.5 ± 0.3
4
Conclusions
C
Fig. 5: Socket seal surgery on a left central incisor (A: Baseline; B: Insertion of the graft; C: implant supported provisional crown)
The presented socket seal technique using a epithelized connective tissue graft with a tunneling approach showed promising results in terms of ridge preservation in horizontal and vertical dimensions. Compared to other methods, subpapillar extension of the graft allowed the support of the interdental papillae. This procedure can be recommended in aesthetically critical regions in patients with high aesthetic demands, in particular when there is a thin gingival biotype. Since these data are preliminary and the influence of tooth type and location has not been evaluated further case control studies are recommended in order to verify the benefits of this technique. Email:
[email protected]
EuroPerio 8 - June 3-6 2015, London
