The decision tree is a useful framework for managing the large number of complexities involved in developing treatment plans for edentulous patients. A patient’s suitability for immediate or delayed implant treatment will depend on a number of factors. Although increasingly reliable strategies for enabling immediate implants are available, it is important to ensure conditions are optimal for successful osseointegration before proceeding.
Studies point to primary stability as the basis of implant survival.[i] Creating conditions that prevent the risk of micromovements associated with failure is vital. Many questions remain to guide the clinician’s treatment plan, which should be reassessed at every stage. Has the extraction method preserved enough bone and tissue to indicate immediate placement? Will the socket be best preserved through augmentation, through immediate placement, or through other techniques?
Reducing extraction trauma
There have been many advances in technology in recent years, designed to minimise trauma during the extraction process. A number of studies, however, still favour the manual periotome over alternatives. The long, thin edge of the tool is very successful in gently separating the tooth from the alveolar ridge without damaging bone, periodontal ligaments or surrounding teeth. The periotome is also found to be effective in atraumatically removing endodontically treated teeth as well as teeth with crown-fractures, though a great deal of care is required to prevent tool fracture.[ii]
Piezosurgery is a relatively new technology powered by ultrasonic vibration. The success of the piezosurgery device is now well-established in oral and maxillofacial surgery because of its inherent precision, in addition to its ability to cut bone atraumatically, while preserving soft tissue. The accuracy and strength of piezosurgical instruments means less force is needed, enhancing operator control further. Piezosurgical devices compare well with other surgical devices for superior cutting action with less collateral damage and less bleeding, resulting in improved healing.[iii]
Much of the evidence still favours the use of manual periotomes over the piezotome for atraumatic extraction. This is due to shorter average operating time, lower postoperative visual analogue scale (VAS) pain scores, and lower dosage of analgesics seen over the course of a number of studies. However, piezotomes do maintain better soft-tissue integrity around extracted teeth, and the technology is quickly developing, making it a more and more promising option.[iv]
Socket preservation and immediate implant placement (IIP)
New methodologies have enabled similar survival rates for IIP in fresh extraction sockets as delayed implant placement in healed sockets. Although delayed placement is marginally more predictable, the several advantages of IIP include shortened total treatment time, reduction of the number of invasive surgeries, and subsequent reduction of patient discomfort.[v]
The combination of atraumatic extraction, socket preservation, and IIP can prevent alveolar resorption.[vi] If there is a lack of early bone support, or a gap between the extraction socket and implant, and if it is not possible to cover the fixture with soft tissue, IIP has to be considered alongside socket-preserving mitigations. These include coverage with soft tissue or a membrane and bone augmentation to reduce the risk of micromovement, infection and implant loss.[vii]
Partial extraction therapy has been shown to be successful in preserving the socket, while allowing for IIP. The concept – also known as the socket-shield technique (SST), root membrane technique, or partial root retention – was designed to minimise bone loss, protecting the buccal bone. In this technique, a fragment of tooth is left attached in the socket, and the implant is immediately placed alongside.[viii]
The aim of SST is to preserve the buccal two-thirds of the root in the socket so that the periodontium, along with the bundle bone and the buccal bone remains intact. Once a tooth is extracted, the buccal bone is deprived of the blood supply from the socket side which contributes to bone-loss. The root section preserves the periodontal attachment apparatus, ensuring it remains vital and undamaged. This procedure, however, requires a great deal of precision and skill, and is not recommended for all cases.[ix]
Another socket preservation technique makes use of autologous biomaterial. Platelet-rich fibrin (PRF) is widely available, inexpensive, and has prolonged growth factor release, together with several other advantages over traditionally prepared platelet concentrates.[x] It has been used widely for periodontal intra-bony defects, sinus augmentation, socket preservation, and gingival recession.[xi] Its short-term effectiveness is well-established; however, this diminishes over a period of two weeks as it is resorbed and loses its biological activities.[xii]
Developing confidence and skills for improved decision-making
Ucer Education and ICE Postgraduate Dental Institute and Hospital/University of Salford is offering a comprehensive, advanced course in the theory and practice of managing tooth loss, with a focus on decision-making around immediate implants versus socket preservation. The course is led by eminent specialist oral surgeon, Professor Cemal Ucer, and features the clinical expertise of Dr Ulpee Darbar and Professor Simon Wright. With a combination of theory and hands-on experience, participants will gain a deeper understanding of everything from disuse atrophy, osseointegration and soft tissue management, to bio-enhancement techniques, IIP and loading using analogue or fully digital workflows.
Decision-making is a vital function of the clinician, and should be informed by evidence at every level. Developing the confidence to discern the optimal treatment for patients comes from the acquisition of practical knowledge and skills combined with a strong understanding of all the options available.
Please contact Professor Ucer at ucer@icedental.institute or Mel Hay at mel@mdic.co
01612 371842
Author: Professor Cemal Ucer. BDS, MSc, PhD, Oral Surgeon, ITI Fellow
[i] Javed F, Ahmed HB, Crespi R, Romanos GE. Role of primary stability for successful osseointegration of dental implants: Factors of influence and evaluation. Interv Med Appl Sci. 2013 Dec;5(4):162-7. doi: 10.1556/IMAS.5.2013.4.3. Epub 2013 Dec 20. PMID: 24381734; PMCID: PMC3873594.
[ii] Sharma SD, Vidya B, Alexander M, Deshmukh S. Periotome as an Aid to Atraumatic Extraction: A Comparative Double Blind Randomized Controlled Trial. J Maxillofac Oral Surg. 2015 Sep;14(3):611-5. doi: 10.1007/s12663-014-0723-8. Epub 2014 Nov 8. PMID: 26225052; PMCID: PMC4511886.
[iii] Seshan H, Konuganti K, Zope S. Piezosurgery in periodontology and oral implantology. J Indian Soc Periodontol. 2009 Sep;13(3):155-6. doi: 10.4103/0972-124X.60229. PMID: 20379414; PMCID: PMC2848787.
[iv] Seshan H, Konuganti K, Zope S. Piezosurgery in periodontology and oral implantology. J Indian Soc Periodontol. 2009 Sep;13(3):155-6. doi: 10.4103/0972-124X.60229. PMID: 20379414; PMCID: PMC2848787.
[v] Lee W. Immediate implant placement in fresh extraction sockets. J Korean Assoc Oral Maxillofac Surg. 2021 Feb 28;47(1):57-61. doi: 10.5125/jkaoms.2021.47.1.57. PMID: 33632979; PMCID: PMC7925164.
[vi] Dayakar MM, Waheed A, Bhat HS, Gurpur PP. The socket-shield technique and immediate implant placement. J Indian Soc Periodontol. 2018 Sep-Oct;22(5):451-455. doi: 10.4103/jisp.jisp_240_18. PMID: 30210197; PMCID: PMC6128121.
[vii] Lee W. Immediate implant placement in fresh extraction sockets. J Korean Assoc Oral Maxillofac Surg. 2021 Feb 28;47(1):57-61. doi: 10.5125/jkaoms.2021.47.1.57. PMID: 33632979; PMCID: PMC7925164.
[viii] Dayakar MM, Waheed A, Bhat HS, Gurpur PP. The socket-shield technique and immediate implant placement. J Indian Soc Periodontol. 2018 Sep-Oct;22(5):451-455. doi: 10.4103/jisp.jisp_240_18. PMID: 30210197; PMCID: PMC6128121.
[ix] Kumar PR, Kher U. Shield the socket: Procedure, case report and classification. J Indian Soc Periodontol. 2018 May-Jun;22(3):266-272. doi: 10.4103/jisp.jisp_78_18. PMID: 29962709; PMCID: PMC6009166.
[x] Pavlovic V, Ciric M, Jovanovic V, Trandafilovic M, Stojanovic P. Platelet-rich fibrin: Basics of biological actions and protocol modifications. Open Med (Wars). 2021 Mar 22;16(1):446-454. doi: 10.1515/med-2021-0259. PMID: 33778163; PMCID: PMC7985567.
[xi] Sun XL, Mudalal M, Qi ML, Sun Y, Du LY, Wang ZQ, Zhou YM. Flapless immediate implant placement into fresh molar extraction socket using platelet-rich fibrin: A case report. World J Clin Cases. 2019 Oct 6;7(19):3153-3159. doi: 10.12998/wjcc.v7.i19.3153. PMID: 31624768; PMCID: PMC6795724.
[xii] Lahham, C., Ta’a, M.A., Lahham, E. et al. The effect of recurrent application of concentrated platelet-rich fibrin inside the extraction socket on the hard and soft tissues. a randomized controlled trial. BMC Oral Health 23, 677 (2023). https://doi.org/10.1186/s12903-023-03400-5
