Flapless Alveolar Ridge Preservation Utilizing the “Socket-Plug” Technique: Clinical Technique and Review of the Literature
It has been documented that after every extraction of one or more teeth, the alveolar bone of the respective region undergoes resorption and atrophy. Therefore, ridge preservation techniques are often employed after tooth extraction to limit this phenomenon. The benefits of a flapless procedure include maintenance of the buccal keratinized gingiva, prevention of alterations to the gingival contours, and migration of the mucogingival junction that are often experienced after raising a flap. The purpose of this article is to review the literature concerning flapless ridge preservation techniques with the aid of collagen plugs for occlusion of the socket. The term “socket-plug” technique is introduced to describe these techniques. The basic steps of the “socket-plug” technique consist of atraumatic tooth extraction, placement of the appropriate biomaterials in the extraction site, preservation of soft tissue architecture employing a flapless technique, and placement and stabilization of the collagen plug. A case example is presented that illustrates the steps used in this technique.
Figure 1. Clinical view of an extraction site that was not treated with a ridge preservation technique (black arrows pointing at the residual ridge). Figure 2. Pre-extraction decision tree. Figure 3. A serrated periotome is utilized to severe the periodontal ligament, thus aiding in the atraumatic extraction. Figure 4. The graft is placed up to the level of the bone crest. Figure 5. The collagen plug is used to protect the graft. When the collagen plug is moistened with saline or blood, it becomes malleable so it can easily adapt in the coronal part of the socket.
Figure 6. Preoperative view of the nonrestorable upper left second premolar. Figure 7. The involved tooth was extracted without flap reflection. Figure 8. Immediate postextraction radiographic view of the socket. Figure 9. The socket was filled with an alloplastic graft that displays putty consistency and is easily injected into the socket, thus saving important clinical time. Figure 10. A collagen plug is trimmed and adapted over the graft in order to occlude the socket. Figure 11. Clinical view of the healed site 18 months post extraction. The dimensional stability of the ridge will allow for the ideal restoratively driven positioning of an implant. Figure 12. Radiographic image of the socket at the 18-month recall appointment. The trabecularization of the regenerated bone is similar to the native bone. Note the pneumatization of the sinus. Figure 13. Calcium phosphosilicate putty core at 6 months. The red-stained tissue is mineralized, newly regenerated bone with visible cell nuclei. Some residual graft particles can be seen in all images. New bone formation is quite robust surrounding particles of bio-active glass. The yellowish-green staining shows osteoid and the newly entrapped osteocytes in the very immature bone. NB indicates new bone; CPS, calcium phosphosilicate putty; OS, osteoid; and OB, osteoblast.
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