Following the extraction of a tooth, dental implants are an excellent option for patients due to their favourable aesthetics and functional capabilities. However, various clinical, biomechanical, and biological conditions must be met for long-term success.[i] Dimensional changes to the alveolar bone start with the loss of bundle bone during the first 7–14 days after a tooth is extracted.[ii] The preservation of bone quality in the alveolar ridge is crucial for maintaining healthy and functional dentition.[iii]
The clinician must rely on the best evidence to guide them on the management of the extraction site – the timing of implant placement, as well as the appropriateness of socket augmentation protocols. Where socket augmentation is indicated, many different bio-enhancement techniques now exist to minimise bone loss following an extraction. This field of study is rapidly developing, and the acquisition of knowledge and skills around bio-enhancement techniques in alveolar ridge preservation (ARP) has become an expectation within the competency of the advanced practitioner.[iv]
Contemporary ridge preservation techniques
Immediate placement of dental implants into the extraction socket following tooth extraction is a common contemporary solution for preserving the alveolar ridge, with or without simultaneous bone augmentation.[v] However, primary stability and aesthetics may be challenged if bone quality is not sufficient, and immediate placement is not always indicated.[vi]
Socket augmentation is recommended to maintain the shape of the alveolar ridge when immediate or early implant placement with sufficient primary stability cannot be achieved. This may be due to significant bone defects, compromised socket walls, or unfavourable conditions of the soft tissue.[vii]
In guided bone regeneration (GBR), barrier membranes are implanted over a tissue defect, to protect a bone graft from cell invasion from the gingival epithelium and connective tissue. This technique is widely accepted, but also presents risks, like membrane exposure, wound dehiscence or infection.[viii] Non-biodegradable barrier membranes are advantageous for supporting large-scale tissue regeneration, however, they require surgical intervention to remove the membrane.[ix]
The use of bone substitute materials (BSM) in oral surgery and implantology has been employed since the 1970s with the use of hydroxyapatite (HA).[x] Contemporary ARP makes use of many bioactive materials, encompassing HA, collagen, and 3D bone repair materials. Biomimetic materials containing hydrogels, stem cells and vascular endothelial cells, for example, can be engineered and printed, promoting enhanced integration and regeneration.[xi]
A buccal fat pad (BFP) can be used as a natural barrier to cover non-resorbable devices for vertical ridge augmentation.[xii] Using BFP flaps to repair oral defects has proven to be efficient in bone augmentation. The adipose tissue deposits along the anterior border of the masseter muscles can be used for the repair of oral defects, and are a rich and easily accessible source of mesenchymal stem cells.[xiii]
Autologous platelet concentrates
Platelets are a major source of autogenous growth factors, which were first employed in the 1970s with platelet-rich plasma (PRP), a blood based therapy which involves injecting concentrated plasma into a site of injury.[xiv]
Platelet-rich fibrin (PRF), developed in 2001, is a biomaterial derived from a patient’s own blood, consisting of a concentrated fibrin matrix containing platelets, white blood cells (leukocytes), and growth factors. PRF acts as a scaffold to promote tissue regeneration and wound healing. Unlike PRP, PRF doesn’t require added anticoagulants during preparation.[xv] Numerous studies have shown that the use of autogenous PRF platelet concentrates during ARP reduces healing time, and improves angiogenesis and bone regeneration. PRF promotes socket sealing by enhancing the fibrin matrix. Additionally, it decreases post-extraction pain and has antibacterial properties, reducing the risk of infection.[xvi]
Concentrated growth factors (CGF) are the most recent generation of platelet substitutes. Created in 2006, CGF maximises the concentration of growth factors such as vascular endothelial growth factor (VEGF), transforming growth factor-β1 (TGF-β1) and β2 (TGF-β2), fibroblast growth factor (FGF), platelet-derived growth factor (PDGF) and insulin-like growth factor (IGF) present in blood platelets. CGF treatment is promising, and may well be a simple and low-cost solution in the near future, but the evidence is still emerging to confirm its appropriate application.[xvii]
Evolving protocols
Bio-enhancement and alveolar ridge preservation protocols are evolving in line with advancements in surgical techniques, biomaterials and in the science examining the biological mechanisms behind bone growth. Staying abreast of the evidence to support effective ARP is essential for the advanced dentist.
Eminent specialist oral surgeon, Professor Cemal Ucer, examines these in the Advanced Certificate in Management of Tooth Loss: Immediate Implants vs Socket Preservation course at the ICE Postgraduate Institute and Hospital. The comprehensive course includes lectures, workshops and hands-on experiences with expert practitioners, covering all aspects of tooth loss management, including hands-on practical experience in socket augmentation and alveolar ridge preservation.
Many techniques exist to minimise the loss of bone following the extraction of a tooth. Developing the confidence and critical skills to develop an evidence-based treatment plan as this exciting field of study evolves is an essential requirement for a serious practitioner.
Please contact Professor Ucer at ucer@icedental.institute or Mel Hay at mel@mdic.co
01612 371842
Prof. Cemal Ucer, BDS, MSc, PhD, FDTFEd., ITI Fellow, Specialist Oral Surgeon
Cemal Ucer first established an implant referral centre in 1995. He was awarded an MSc in Implantology at Manchester Dental Hospital following his research into guided bone regeneration and osteopromotion. He later gained a PhD for his clinical and laboratory studies into the factors affecting the success of implant treatment in iliac grafts and the investigation of the effect of skeletal bone density on implant survival. He has personally trained and mentored more than 1,000 dentists in implant dentistry as one of the main providers of implant education in the UK.
Cemal’s current clinical research interests include immediate implant placement, reconstructive bone surgery, nerve damage and the effect of bone density on the success of implant treatment. Academically, he has gained European recognition for his work on the development of a new framework for teaching and assessment of clinical competence in implantology. He is a co-author of the consensus paper produced by the Association for Dental Education in Europe (ADEE) following the first pan-European collaboration between EU universities to establish common training and assessment standards in dental implantology. He is an invited member of the working group convened by the FGDP (UK) and the General Dental Council (GDC) to update the Training Standards in Implant Dentistry (TSID) guidelines in 2012 and 2016.
Cemal is a Fellow of the Dental Trainers Faculty of the Royal College of Surgeons of Edinburgh (RCSEd) and a Fellow of the International Team for Implantology (ITI) and a member of Megagen’s MINTEC UK & I Board for education and clinical research. He is a member of the editorial board of JOMR (Journal of Oral & Maxillofacial Research) and the chair of the editorial advisory board of Implant Dentistry Today. Cemal is Professor and Clinical Lead of the MSc programme in Dental Implantology and a member of the Faculty of Examiners of the Royal College of Surgeons of Edinburgh’s Diploma in Implant Dentistry. He is a past president of The Association of Dental Implantology (ADI) (2011-2013).
Cemal has been appointed by FGDP (UK) to lead the working group to develop the “national standards in implant dentistry” which is due to be published later in 2018 following the completion of an external consultation process.
[i] Alasqah M, Alansary RD, Gufran K. Efficacy of Platelet-Rich Fibrin in Preserving Alveolar Ridge Volume and Reducing Postoperative Pain in Site Preservation of Post-Extracted Sockets. Medicina. 2024; 60(7):1067. https://doi.org/10.3390/medicina60071067
[ii] Ucer C, Khan RS. Extraction Socket Augmentation with Autologous Platelet-Rich Fibrin (PRF): The Rationale for Socket Augmentation. Dent J (Basel). 2023 Aug 14;11(8):196. doi: 10.3390/dj11080196. PMID: 37623292; PMCID: PMC10453157.
[iii] Kim S, Kim SG. Advancements in alveolar bone grafting and ridge preservation: a narrative review on materials, techniques, and clinical outcomes. Maxillofac Plast Reconstr Surg. 2024 Apr 16;46(1):14. doi: 10.1186/s40902-024-00425-w. PMID: 38625426; PMCID: PMC11021384.
[iv] Elayah SA, Younis H, Cui H, Liang X, Sakran KA, Alkadasi B, Al-Moraissi EA, Albadani M, Al-Okad W, Tu J, Na S. Alveolar ridge preservation in post-extraction sockets using concentrated growth factors: a split-mouth, randomized, controlled clinical trial. Front Endocrinol (Lausanne). 2023 May 17;14:1163696. doi: 10.3389/fendo.2023.1163696. PMID: 37265705; PMCID: PMC10231034.
[v] Al-Aroomi OA, Sakran KA, Al-Aroomi MA, Mashrah MA, Ashour SH, Al-Attab R, Yin L. Immediate implant placement with simultaneous bone augmentation versus delayed implant placement following alveolar ridge preservation: A clinical and radiographic study. J Stomatol Oral Maxillofac Surg. 2023 Feb;124(1S):101291. doi: 10.1016/j.jormas.2022.09.012. Epub 2022 Sep 22. PMID: 36155090.
[vi] Kim S, Kim SG. Advancements in alveolar bone grafting and ridge preservation: a narrative review on materials, techniques, and clinical outcomes. Maxillofac Plast Reconstr Surg. 2024 Apr 16;46(1):14. doi: 10.1186/s40902-024-00425-w. PMID: 38625426; PMCID: PMC11021384.
[vii] Ucer C, Khan RS. Extraction Socket Augmentation with Autologous Platelet-Rich Fibrin (PRF): The Rationale for Socket Augmentation. Dent J (Basel). 2023 Aug 14;11(8):196. doi: 10.3390/dj11080196. PMID: 37623292; PMCID: PMC10453157.
[viii] Kim YK, Ku JK. Guided bone regeneration. J Korean Assoc Oral Maxillofac Surg. 2020 Oct 31;46(5):361-366. doi: 10.5125/jkaoms.2020.46.5.361. PMID: 33122463; PMCID: PMC7609932.
[ix] Sasaki JI, Abe GL, Li A, Thongthai P, Tsuboi R, Kohno T, Imazato S. Barrier membranes for tissue regeneration in dentistry. Biomater Investig Dent. 2021 May 20;8(1):54-63. doi: 10.1080/26415275.2021.1925556. PMID: 34104896; PMCID: PMC8158285.
[x] Monroe E A, Votava W, Bass D B, McMullen J. New calcium phosphate ceramic material for bone and tooth implants. J Dent Res 1971; 50: 860-861.
[xi] Kim, S., Kim, SG. Advancements in alveolar bone grafting and ridge preservation: a narrative review on materials, techniques, and clinical outcomes. Maxillofac Plast Reconstr Surg 46, 14 (2024). https://doi.org/10.1186/s40902-024-00425-w
[xii] Cucchi A, Randellini E, Bettini S, Corinaldesi G. Effectiveness of Bichat’s Buccal Fat Pad (BFP) Technique for Vertical Ridge Augmentation in the Maxilla. Int J Periodontics Restorative Dent. 2023 Mar, Apr;43(2):e99-e109. doi: 10.11607/prd.5473. PMID: 37232689.
[xiii] Favero G, van Noorden CJF, Rezzani R. The Buccal Fat Pad: A Unique Human Anatomical Structure and Rich and Easily Accessible Source of Mesenchymal Stem Cells for Tissue Repair. Bioengineering. 2024; 11(10):968. https://doi.org/10.3390/bioengineering11100968
[xiv] Ucer C, Khan RS. Alveolar Ridge Preservation with Autologous Platelet-Rich Fibrin (PRF): Case Reports and the Rationale. Dent J (Basel). 2023 Oct 23;11(10):244. doi: 10.3390/dj11100244. PMID: 37886929; PMCID: PMC10605266.
[xv] Grecu AF, Reclaru L, Ardelean LC, Nica O, Ciucă EM, Ciurea ME. Platelet-Rich Fibrin and its Emerging Therapeutic Benefits for Musculoskeletal Injury Treatment. Medicina (Kaunas). 2019 May 15;55(5):141. doi: 10.3390/medicina55050141. PMID: 31096718; PMCID: PMC6572609.
[xvi] Ucer C, Khan RS. Alveolar Ridge Preservation with Autologous Platelet-Rich Fibrin (PRF): Case Reports and the Rationale. Dent J (Basel). 2023 Oct 23;11(10):244. doi: 10.3390/dj11100244. PMID: 37886929; PMCID: PMC10605266.
[xvii] Liu, Y., Li, X., Jiang, C. et al. Clinical applications of concentrated growth factors membrane for sealing the socket in alveolar ridge preservation: a randomized controlled trial. Int J Implant Dent 8, 46 (2022). https://doi.org/10.1186/s40729-022-00448-w
