Socket Preservation Procedure after Tooth Extraction

Various materials are used in modern dental and maxillofacial surgery for bone tissue substitution and reconstruction. All osteoplastic materials can be divided into four groups by origin: autogenic, allogenic, xenogenic and synthetic. Synthetic resorbable materials were intended as an inexpensive substitute for natural bone. Synthetic graft materials include various types of ceramics: tricalcium phosphate; bioglass; hydroxyapatite and its compositions with collagen, sulphated glycosaminoglycans such as keratan and chrondroitin sulphates well as with sulphate and calcium phosphate. Jaw deformities from tooth removal can be prevented and repaired by a procedure called socket preservation. The procedure begins with atraumatic tooth extraction. Every attempt is made to preserve the surrounding bone and soft tissue, with an emphasis on being careful not to fracture the delicate buccal plate. There are a number of techniques and instruments that aid in this process. In general, one never wants to elevate so that force is directed toward the buccal plate. It is important that good bleeding is established in the socket. Next, a bone graft material is placed into the socket and covered with a resorbable or non-resorbable membrane and sutured. Most importantly, socket preservation helps to maintain the alveolar architecture and significantly reduces the loss of ridge width and height following tooth removal. Introduction The indications for teeth extractions are different. Sometimes it is necessary because of pain, infection, bone loss or fracture of the tooth. The bone that holds the tooth in place (the socket) is often damaged by disease and/or infection resulting in deformity of the jaw after the tooth is extracted. In addition, when teeth are extracted, the surrounding bone and gums can shrink and recede very quickly after the extraction resulting in unsightly defects and collapse of the lips, and cheeks. The loss of alveolar bone may be attributed to a variety of factors, such as endodontic pathology, periodontitis, facial trauma and aggressive manoeuvres during extractions. These jaw defects can create major problems in performing restorative dentistry whether the treatment involves dental implants, bridges or dentures [1]. Jaw deformities from tooth removal can be prevented and repaired by a procedure called socket preservation. Socket preservation can greatly improve the smile’s appearance and increase the chances for successful dental implants for years to come. Several studies, clinical case series and literature reviews in peer-reviewed journals were examined in detail to establish a rationale for using socket preservation as a therapeutic option following tooth extraction. This review describes the socket preservation, and the various techniques and materials used for extraction site grafting. In the current review of the literature, techniques for alveolar ridge preservation are discussed [2]. Biological mechanism of bone grafting [3] are based on: • Osteoconduction when the bone graft material serves as a scaffold for new bone growth that is perpetuated by the native bone. • Osteoinduction involves the stimulation of osteoprogenitor cells to differentiate into osteoblasts that then begin new bone formation. The most widely studied type of osteoinductive cell mediators are bone morphogenetic proteins (BMPs). Key Engineering Materials Vol. 587 (2014) pp 325-330 © (2014) Trans Tech Publications, Switzerland doi:10.4028/www.scientific.net/KEM.587.325 All rights reserved. No part of contents of this paper may be reproduced or transmitted in any form or by any means without the written permission of TTP, www.ttp.net. (ID: 79.126.203.119, University “Goce Delcev”, Stip, Macedonia-05/10/13,03:08:29) • Osteogenesis occurs when vital osteoblasts originating from the bone graft material contribute to new bone growth along with bone growth generated via the other two mechanisms. • Osteopromotion involves the enhancement of osteoinduction without the possession of osteoinductive properties. For example, enamel matrix derivative has been shown to enhance the osteoinductive effect of demineralized freeze dried bone allograft (DFDBA), but will not stimulate de novo bone growth alone. Consequences of tooth and jaw bone loss The importance of teeth for jaw bone health is extensively exploited in the contemporary scientific literature. When one or more teeth are missing, it can lead to jawbone loss at the site of the gap. This loss of jawbone can develop into additional problems, both with the patient’s appearance and overall health. Natural teeth are embedded in the jawbone, and stimulate the jawbone through activities such as chewing and biting [2]. When teeth are missing, the alveolar bone, or the portion of the jawbone that anchors the teeth in the mouth, no longer receives the necessary stimulation, and begins to breakdown, or resorb. The body no longer uses or “needs” the jawbone, so it deteriorates [4]. Without intervention (natural healing), the results of all nine studies showed a significant loss of ridge width (−2.6 to −4.6 mm), and the results of five studies showed a statistically significant loss of bony ridge height (−0.55 to −3.3 mm). No significant reduction in ridge height from baseline was found with certain socket preservation interventions. There are several reasons to consider preservation of the alveolar socket immediately following tooth extraction [4, 5]: • One reason for placing a graft of a synthetic biomaterial is to stabilize the coagulum within the socket and avoid possible reduction of the hard tissue volume required for bone regeneration. Although vertical bone resorption can be expected as part of the physiologic pattern of bone healing after tooth extraction, in most of the cases no reduction in the vertical dimension of the alveolar ridge had occurred 9 months after tooth extraction. The ridge width (12 mm) did not change either. More studies involving larger samples, better sample standardization, more defined measurements, masking and esthetic restorative outcomes are needed. • Another reason for placing a graft into an extraction socket is to provide a scaffold for the ingrowth of cellular and vascular components to form new bone of acceptable quality and quantity. Alveolar ridge resorption has long been considered an unavoidable consequence of tooth extraction. Atrophy of the alveolar bone may cause significant esthetical and surgical problems in implantation, as well as at prosthetic and restorative dentistry [1]. The potential consequences of tooth and jawbone loss are several: problems with remaining teeth, including misalignment, drifting, loosening and loss; collapsed facial profile, limited lip support; skin wrinkling around the mouth, distortion of other facial features; difficulty speaking and communicating; inadequate nutrition as a result of the inability to chew properly and painlessly, sinus expansion [6]. Socket preservation is an indispensable procedure, the all-important as well as fundamental is to prevent bone loss following tooth extraction. Preservation as the name has it is the maintenance of the socket, which is essentially the height and width of the gap that is left after the tooth is removed. It is done by placing a graft material or scaffold immediately into the socket of an extracted tooth to preserve bone height, width and density. [6]. After tooth extraction, the residual alveolar ridge generally provides limited bone volume because of ongoing, progressive bone resorption. Healing events within postextraction sockets reduce the dimensions of the socket over time. A reduction of about 50% in both horizontal and vertical directions has been observed over 12 months, with two-thirds of the reduction occurring in the first three months. The rate and pattern of bone resorption may be altered if pathologic and traumatic processes have damaged one or more of the bony walls of the socket. In these circumstances, fibrous tissue will likely occupy part of the socket, preventing normal healing and osseous regeneration. These morphologic changes may affect the successful placement and osseointegration of dental implants [4]. 326 Bioceramics 25