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Periodontology 2000, Vol. 0, 2018, 1–11 © 2018 John Wiley & Sons A/S.

ley & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved PERIODONTOLOGY 2000

Alveolar ridge preservation in the


esthetic zone
€ MERLE &
R O N A L D E. J U N G , A L E X I S I O A N N I D I S , C H R I S T O P H H. F. H AM
D A N I E L S. T H O M A

Anatomy of the extraction socket in Therefore, in the esthetic zone, the clinician is con-
the esthetic zone fronted with a challenging situation regarding the
decision-making process required to provide an opti-
Following tooth extraction, alveolar bone loss and mal treatment solution. Hence, in recent years, the
structural and compositional changes of the covering healing process of the extraction socket and the
soft tissues, as well as morphological alterations, can related changes of respective hard and soft tissues fol-
be expected (30). The numerous alterations in the lowing tooth removal has become a well-investigated
alveolar process may lead to difficulties at the time of research field. Ideally, the therapeutic plan starts
implant placement when a prosthetically driven before tooth extraction and offers three therapeutic
implant position is desired (11). options: spontaneous healing of the extraction socket;
In order to understand the changes following tooth immediate implant placement; and techniques for
extraction in the esthetic zone, it is fundamental to preserving the alveolar ridge at the site of tooth
comprehend the anatomic and histologic characteris- removal. This narrative review focuses on alveolar
tics of tissues surrounding the tooth foreseen for ridge preservation techniques in the esthetic zone.
extraction. Being part of the periodontium, the alveo- Besides the evidential background of alveolar ridge
lar process surrounds the fully erupted tooth. Histo- preservation procedures, this article provides a clini-
logically, the inner part of the socket wall contains cal decision tree and corresponding cases demon-
lamellar bone, the so-called bundle bone (2). The strating the different treatment options.
thickness of this bundle bone is reported to be 0.2–
0.4 mm (29). Similarly to the root cementum and to
the periodontal ligament, its existence is strictly Spontaneous healing following
tooth-dependent (2). tooth extraction
In a recent clinical study, the thickness of the buc-
cal bone plate in the maxillary anterior area was mea- After tooth extraction, the alveolar ridge undergoes
sured using cone beam computed tomography (18). evident reduction in both vertical and horizontal
The thickness of the buccal bone plate was measured directions (7, 8, 19). The processes taking place after
at three different positions relative to the buccal bone tooth removal were systematically reviewed in an
crest (18). It was found that the buccal bone plate, in article that included 20 human studies and aimed to
most locations in the anterior maxilla, is less than assess the magnitude of dimensional changes of both
1 mm in thickness. In addition, nearly 50% of the the hard and soft tissues of the alveolar ridge after
sites investigated had a bone plate, which was (at tooth extraction (35). Based on the evidence of the
maximum) 0.5 mm thick. This, is turn, means that review, the vertical dimensional reduction on the
the bundle bone and the buccal bone plate com- buccal side amounted to 11–22% ( 1.24  0.11 mm)
monly have a similar thickness in the anterior maxil- after 6 months, whereas the horizontal dimensional
lary region. Therefore, one might assume that, after reduction on the buccal side was greater, amounting
tooth extraction in the esthetic area, the buccal bone to 29–63% ( 3.79  0.23 mm) after 6–7 months (35).
plate will be resorbed predominantly in the more It was concluded that human re-entry studies demon-
crestal region. strated rapid alteration within the first 3–6 months

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Jung et al.

after tooth removal, followed by gradual reduction in results in a reduction of the ridge dimension of about
dimension thereafter. Subsequently, 0.5–1% reduc- half of the initial bone width in a horizontal dimen-
tion of the bone contour, per year, can be expected sion and therefore seems not to be beneficial when
(6). In summary, following single-tooth extraction, up compared with spontaneous healing (2, 10). However,
to 50% of the ridge width will be resorbed and bone less horizontal bone resorption can be expected by
resorption will predominantly occur at the buccal addition of a grafting material and by combining
aspect (2). immediate implant placement with a guided bone-
regeneration procedure.

Immediate implant placement


Alveolar ridge preservation
Immediate implant placement can be performed in a procedures
variety of therapeutic procedures – either with or
without flap elevation and with or without additional Alveolar ridge preservation techniques have been
guided bone-regeneration procedures. The alter- widely used in the past and are continuously evalu-
ations in hard tissue following immediate implant ated. These techniques are performed to counteract
placement without guided bone-regeneration proce- changes in soft tissue and hard tissue that follow
dures were evaluated in a study including 18 patients tooth extraction. More recent research has focused
with a total of 21 teeth scheduled for extraction (10). on a variety of materials and techniques and has dif-
Following flap elevation and tooth removal, an ferent aims depending on the need for preservation
implant was placed without additional membranes or of soft tissue and/or hard tissue, as well as on the
bone-substitute materials (10). The follow-up exami- optimization of the ridge profile. According to previ-
nation at 4 months of healing demonstrated horizon- ous systematic reviews (14, 16, 24, 40), three options
tal resorption of the buccal bone dimension of for alveolar ridge preservation exist: the use of soft-
approximately 56% at the buccal aspect and 30% at tissue grafts; the use of hard-tissue graft materials; or
the lingual and palatal aspects (10). This is underlined the use of a combination of soft-tissue and hard-
by further preclinical and clinical studies demonstrat- tissue biomaterials. The main goals include: the elimi-
ing that immediate implant placement in a fresh nation, or at least a limitation, of post extraction ridge
extraction socket fails to prevent bone resorption alterations; the promotion of healing of soft and hard
(3–5, 15, 26, 28). tissue within the former extraction socket; and facili-
The outcomes of immediate implants were also tating the placement of dental implants in a prosthet-
assessed concomitant with guided bone-regenera- ically ideal position without the need for further
tion procedures (12). The aim of that prospective augmentative procedures (16, 24). From a clinical
clinical study was to evaluate the clinical perfor- point of view, the decision to perform a certain alveo-
mance of immediately placed implants. In total, 30 lar ridge preservation technique depends mainly on:
patients received immediate transmucosal implants (i) the time-point chosen and the ability to place a
in the maxillary anterior region. The patients were dental implant; (ii) the quality and quantity of soft tis-
randomly assigned into three treatment groups: 10 sue in the region of the extraction socket; (iii) the
patients received implants without additional remaining height of the buccal bone plate; and (iv)
guided bone-regeneration procedures; 10 patients the expected implant survival and success rates. Ide-
received implants grafted with demineralized ally, from a patient’s perspective, dental implants
bovine bone matrix alone; and 10 patients received should be placed immediately. However, this tech-
implants grafted with demineralized bovine bone nique is associated with a number of limitations and
matrix and a collagen membrane. The horizontal may not be suitable in all cases. This is mostly
resorption at 4 years amounted to 48.3% in the because of existing deficiencies in terms of bone and
group without grafting material, whereas in the soft tissues. Three healing time-points are described
other two groups significantly less horizontal in the literature for alveolar ridge preservation; these
resorption was observed: 15.8% in the group with focus on the need for: (i) optimization of the soft tis-
demineralized bovine bone matrix; and 20% in the sues (soft-tissue preservation with 6–8 weeks of heal-
group with demineralized bovine bone matrix and ing after tooth extraction); (ii) optimization of the
a collagen membrane (12). hard and soft tissues (hard- and soft-tissue preserva-
In summary, immediate implant placement with- tion with 4–6 months of healing after tooth
out additional guided bone-regeneration procedures extraction); and (iii) optimization of hard tissues

2
Alveolar ridge preservation in the esthetic zone

(hard-tissue preservation with > 6 months of healing graft harvested from the palate (21). This study
after tooth extraction) (13). demonstrated successful integration of the soft-tissue
graft; however, volumetric changes and implant-
related outcomes were not assessed. More recent
Preservation of soft tissue
studies have evaluated the same combination and
Alveolar ridge preservation procedures have been compared different alveolar ridge preservation tech-
described to enhance the quality and/or regenerate niques also using a soft-tissue substitute (collagen
the quantity of the soft tissues that demonstrate a defi- matrix) (1, 20, 23). It was demonstrated that after a
ciency prior to, or after, tooth extraction. From a mate- healing period of 6 months, alveolar ridge preserva-
rial point of view, the options available include the use tion with a xenograft and sealing of the extraction
of an autogenous subepithelial connective tissue graft socket with an autogenous soft tissue graft or a colla-
harvested from the tuberositas area or the palate, a gen matrix were effective (20, 23, 27) and even supe-
free gingival graft harvested from the palate, or a soft- rior to the results observed in control groups
tissue substitute or a resorbable membrane that (spontaneous healing or a biomaterial without a seal)
enhances closure of the soft-tissue wound (9, 21, 31– (20). Horizontal and vertical changes were minimal
34). These procedures are performed predominantly (20) and allowed placement of dental implants with
using a flapless approach or with a minimal coronal high survival rates at the 1-year follow-up (27). Histo-
flap advancement, in order to preserve or gain kera- logic outcome measures additionally revealed that
tinized tissue. Scientific evidence ranges from a variety the placement of a graft material within the socket
of preclinical studies to clinical studies applying differ- retarded healing. Moreover, the presence of the bio-
ent biomaterials also at the level of the hard tissue (17, material within the extraction socket appeared to be
22, 36, 41). As the healing period for such an interven- a major contributing factor for the minimal dimen-
tion is kept to 6–8 weeks, only minimal new-bone for- sional changes observed (1, 23). Furthermore, it was
mation can be expected within the socket, but demonstrated that soft-tissue substitutes could be
complete soft-tissue closure (23). The biomaterials successfully used as a socket seal for alveolar ridge
mainly serve as a space-maintaining device for the preservation, allowing for simplification of the proce-
biomaterial or the graft placed at the soft-tissue level. dure. The use of autogenous grafts may be avoided,
As a result of heterogeneity of the studies using various thereby reducing the postoperative morbidity of
biomaterials and techniques, outcomes are difficult to patients (20, 27).
compare. To date, however, an autogenous soft-tissue
graft appears to be the most suitable method for opti-
Preservation of hard tissue
mizing the ridge profile at the soft-tissue level during
short-term healing periods (37, 38). Alternative soft-tis- In the case of severe loss (> 50%) of the buccal bone
sue substitutes, which appear to reduce postoperative plate, preservation of hard tissue with a prolonged heal-
morbidity (39), have not been documented as exten- ing time before implant placement has been suggested.
sively for short healing periods and can currently not For that purpose, alveolar ridge preservation is per-
replace the use of autogenous tissue (38). formed using a bone-substitute material covered with a
membrane followed by flap advancement to achieve
complete or partial wound closure (most commonly
Preservation of hard tissue and soft tissue
used), a bone-substitute material with full wound clo-
In some clinical cases, deficits in both hard and soft sure achieved by coronal advancement or rotation of
tissue may be observed following tooth extraction. In the flap (the second most-common technique) or a
these cases, more recent techniques suggest a combi- bone-substitute material without wound closure (weak-
nation of soft- and hard-tissue preservation with a est evidence) (14, 40). Various materials were used for
longer-term healing period (4–6 months), applying a these procedures, but none of the material or tech-
minimally invasive, nonflapped approach. These so- niques demonstrated were more favorable than others
called socket seal techniques combine the use of bio- (24). Based on meta-analyses, statistically significantly
materials that are placed at the bony level and of less reduction of bone height (vertical dimension) for
autogenous soft-tissue grafts or of soft-tissue substi- alveolar ridge preservation was observed compared
tutes at the level of the soft tissues (20, 23, 25, 27). In with control groups (weighted mean differ-
one of the earlier studies, a xenogenic bone-substi- ence = 1.47 mm) and statistically significantly less
tute material with 10% collagen was used, and a soft- reduction of bone width (horizontal dimension) for
tissue seal was obtained with a free gingival punch alveolar ridge preservation was observed compared

3
Jung et al.

with controls (weighted mean difference = 1.83 mm). alveolar ridge preservation in daily routine practice.
In addition, a significant, positive effect of flapped sur- Similar data with no differences in terms of implant sur-
gery was observed (40). This clearly demonstrated supe- vival and success rates and marginal bone level changes
riority of alveolar ridge preservation compared with are reported for alveolar ridge preservation sites and
control groups regarding changes of the ridge profile control sites (24). Overall, the data derived from the lit-
following tooth extraction. Apart from benefits in terms erature support the use of alveolar ridge preservation to
of changes in soft and hard tissue, other outcomes, preserve the ridge volume, mainly at the hard tissue
such as the need for further bone augmentation, the level, but do not offer more clinical benefits in terms of
feasibility of implant placement and implant survival implant-related outcomes, and are associated with a
and success rates, might further support the use of alve- long healing period (> 6 months) and a flapped
olar ridge preservation techniques. Based on a more procedure.
recent systematic review, meta-analyses demonstrated
a need for further bone augmentation at implant place-
ment, ranging between 0% and 15% for alveolar ridge Clinical concept for alveolar ridge
preservation and between 0% and 100% for sponta- preservation procedures
neous healing (24). This indicated a decrease in the
need for further bone augmentation with a relative risk
Clinical decision-making process
of 0.15 (95% confidence interval: 0.07–0.30) for alveolar
ridge preservation compared with controls. As in all the When it comes to the esthetic area, the clinical con-
studies included, implant placement was feasible, no cept in today’s dentistry has clearly changed in a way
advantage of alveolar ridge preservation compared with that the treatment plan and the decision-making pro-
controls is evident. Whereas this may not be in favor of cess should take place before a tooth is extracted.
alveolar ridge preservation procedures per se, one needs This allows the patient to benefit from the multiple
to understand that implant placement, in most cases, treatment options that are available at the time of
can be conducted independently of whether or not tooth extraction.
alveolar ridge preservation or spontaneous healing is All treatment modalities have their individual
performed. Given the fact that backwards planning and aims, clinical indications and limitations (Table 1).
not bone-driven implant placement appears to be the The aim of this part of the review is to present a
state-of-the-art in implant therapy, it is crucial to report decision tree (Fig. 1) followed by a therapeutic con-
where the implants were placed, which diameters were cept illustrated by clinical cases (Figs. 2–5). Figure 1
used and which angulation was chosen. This informa- shows the decision tree, which starts with the most
tion can currently not be derived from the scientific evi- general question that needs to be asked before a
dence and therefore might underestimate the effect of tooth is going to be extracted (Question 1): Is

Table 1. Individual aims, clinical indications and limitations of treatment modalities

Treatment option Aim Clinical indications Limitations

Soft-tissue Improve the quantity Ankylosed teeth with vertical Teeth with acute infections.
preservation and quality of soft-tissue deficiencies. Large bone defects
soft tissues at the Teeth with soft-tissue recessions Technique sensitive in terms of
time of tooth extraction. Teeth lacking keratinized tissue soft-tissue management in sites
with extensive soft-tissue defects
Hard- and Regenerate and preserve Small buccal bone defects The socket seal technique does not
soft-tissue the hard tissue and the (less than 50% of the buccal allow for 100% preservation of the
preservation soft tissue at the time of bone plate missing), with or ridge contour and therefore needs,
(socket seal tooth extraction without without soft-tissue defects. in highly esthetic areas, a further
technique) flap elevation. As a method for implant small contour augmentation.
placement 4–6 months thereafter
Pontics of conventional
reconstructions
Hard-tissue Regenerate and augment Large buccal bone defects (> 50% Invasive surgery at the time of tooth
preservation the alveolar bone at of the buccal bone plate missing), extraction without implant
(guided bone the time of tooth extraction. scheduled for late (> 6 months) placement.
regeneration) implant placement. Long healing time

4
Alveolar ridge preservation in the esthetic zone

implant placement possible or indicated within the according to Chen et al. (13)] is indicated. The
next 0–2 months after tooth extraction? If the decision on the timing for implant placement is
answer is ‘yes’ (Answer 1.1), and implant placement based on patient-related, clinical and radiographic
is possible and indicated within the next 0–2 findings and is not part of the present review.
months, an alveolar ridge preservation procedure is In cases with soft-tissue deficiencies and defects at
generally not indicated. However, an additional the time of tooth extraction, a soft-tissue preservation
question needs to be asked before tooth extraction technique (soft-tissue preservation) is indicated in
(Question 2.1): Do the soft tissues need to be opti- order to improve the soft tissues at this early time-
mized prior to implant placement? If the answer is point (Answer 2.2). This generally includes the need
‘no’ (Answer 2.1), the extraction socket is left for for bone graft materials and autogenous soft-tissue
spontaneous healing with subsequent implant grafts. If the answer is ‘no’ and implant placement is
placement 6–8 weeks later [Type 2 implant place- not possible or is indicated at a later time-point
ment according to Chen et al. (13)] or an immedi- (> 2 months) an alveolar ridge preservation proce-
ate implant placement [Type 1 implant placement dure might be recommended according to today’s

A2.1 A2.2 A2.3 A2.4


small big
no yes
< 50% > 50%

Fig. 1. Clinical decision tree, leading to the different alveolar ridge-preservation procedures. A, Answer; Q, Question.

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Jung et al.

A B C D

E F G H

I J K L

M N O P

Fig. 2. (A) Ankylosed tooth #11 revealing a vertical soft- the augmented site. (H) Suture removal after 7 days. (I, J)
and hard-tissue deficiency. (B) Atraumatic tooth extraction. Situation after a healing period of 3.5 months. (K, L, M, N)
(C) Partial flap elevation using a tunnel technique. (D) Fill- Implant placement with a simultaneous guided bone-
ing the extraction socket with a deproteinized bovine bone regeneration procedure. (O) Suture removal after 1 week of
mineral embedded in a 10% collagen matrix. Placement of healing. (P) Five-year follow-up of the all-ceramic implant-
a connective tissue graft (E) underneath the elevated gin- retained crown in the region #11 and the veneer on tooth
giva (F). (G) Postoperative situation after adjusting the tem- #21, showing a harmonious esthetic outcome.
porary removable prosthesis to avoid excessive pressure on

literature (Answer 1.2). In order to identify the most Clinical concept for soft-tissue
appropriate technique, the subsequent question is preservation with an autogenous
related to the amount of remaining buccal bone soft-tissue graft
(Question 2.2): Size of bone defects at the extraction
socket? If less than 50% of the buccal bone plate is The clinical concept starts in general with a correct
missing, a flapless ridge preservation procedure diagnosis and thorough analysis of the clinical and
(hard- and soft-tissue preservation = socket seal radiographic situations. Depending on the difficulty
technique) using a slowly resorbing graft material and of the extraction, the tooth will be removed using
either an autogenous graft or a collagen matrix is either a flapless or an open flap access. A flapless pro-
indicated (Answer 2.3). If more than 50% of the buc- cedure should be selected whenever possible. In a
cal bone plate is missing, good documentation is representative clinical case a 29-year-old woman pre-
available for standard open-flap ridge preservation/ sented with an ankylosed tooth #11 revealing a verti-
augmentation (hard-tissue preservation) using cur- cal soft- and hard-tissue deficiency (Fig. 2). Owing to
rent guided bone regeneration procedures (Answer external buccal root resorption the tooth needed to
2.4). Hence, the more invasive and technique-sensi- be extracted, and the patient had requested an
tive procedure is indicated for larger bone defects, improved esthetic situation. To compensate for the
whereas flapless procedures are indicated for extrac- soft-tissue defect an autogenous connective tissue
tion sockets with smaller bone defects. graft from the palate was selected. A soft-tissue

6
Alveolar ridge preservation in the esthetic zone

substitute or an autogenous punch graft does not maximum (20) additional augmentation of the buccal
allow for augmentation of such an extended defect. contour is needed in cases with a high esthetic
Following atraumatic tooth extraction, a partial flap requirement. Therefore, in the present case, further
elevation using a tunnel technique without any fur- augmentation of the buccal contour, using deminer-
ther incision was performed. The extension of the flap alized bovine bone matrix and a collagen membrane,
elevation includes the buccal, the palatal and the was performed. After a further healing period of
interproximal parts, and should allow for tension-free 2 months, abutment connection was performed and
insertion of the connective tissue graft. After eleva- eventually an all-ceramic implant-retained crown on
tion, the socket was filled with a deproteinized bovine tooth #11 was inserted. In order to close the diastema,
bone mineral embedded in a 10% collagen matrix. a ceramic veneer on tooth #21 and an additional par-
Thereafter, the connective tissue graft was placed tial veneer on tooth #12 were inserted. The 5-year
underneath the elevated gingiva and stabilized by follow-up shows a stable and harmonious esthetic
vertical mattress sutures on the buccal and the palatal outcome.
parts. The orifice of the socket was reduced by cross
sutures. Subsequently, the temporary removable
Clinical concept for hard- and soft-tissue
prosthesis was adjusted to avoid excessive pressure
preservation (socket seal technique)
on the augmented site. The patient received antibi-
using hard- and soft tissue substitutes
otics immediately before tooth extraction and for a
further 5 days postoperatively. Analgesics were pre- A 31-year-old pregnant women presented with a
scribed according to the patient’s need. The patient mesiodistally fractured tooth #24, revealing a high lip
was asked not to mechanically clean this area and to line. As she was pregnant, implant surgery could not
rinse with a chlorhexidine solution (0.2%) for 7–10 days be scheduled and was not expected to be performed
until the day of suture removal. until she had given birth. Hence, it was decided to
After a healing period of at least 6–8 weeks, the next perform an alveolar ridge preservation procedure in
therapeutic interventions can be started. In the pre- order to maintain at least 80–85% of the buccal con-
sent situation the patient received an implant with a tour, facilitating implant placement when the patient
simultaneous guided bone regeneration procedure returned a few months later. As there was no need to
3.5 months later. As flapless ridge preservation can enhance the soft-tissue thickness, it was decided to
only maintain the buccal contour to about 80–85% of perform a socket seal technique using a slowly

A B C D

E F G H

I J K

Fig. 3. (A, B) Mesiodistally fractured tooth #24. Situation (F) Six months after healing. Implant placement without
after tooth extraction (C) and application of demineralized any further augmentation (G, H) and transmucosal healing
bovine bone matrix with collagen (D). (E) Collagen matrix (I). (J, K) Clinical situation, after a further 6 weeks, with a
of 8 mm diameter is sutured to the host gingival margin. screw-retained all-ceramic crown.

7
Jung et al.

resorbing bone-substitute material (demineralized collagen matrix was sutured to the host gingival mar-
bovine bone matrix plus collagen) covered by a colla- gin. Six months later, implant placement was possible
gen matrix (Fig. 3). After gentle tooth extraction and without any further augmentation and the implant
cleaning of the socket using hand instruments and was allowed to heal transmucosally. After a further
saline solution, the demineralized bovine bone matrix 6 weeks, a screw-retained all-ceramic crown was
with collagen was applied and the 8-mm-diameter inserted, revealing a perfect soft-tissue contour.

A B M N

C D O P

E F Q R

G H S T

I J U V

K L

Fig. 4. (A) Central right incisor #11 with buccal fistulae and Implant placement in the correct prosthetically oriented
increased pocket depth. (B) Cone beam computed tomog- position. (K, L) Buccal contour augmentation with dem-
raphy reveals a large apical and pararadicular radiolu- ineralized bovine bone matrix collagen and a collagen
cency involving also the apex of tooth #12. (C) Filling of the membrane. (M, N) Submucosal healing of the implant for
extraction socket, including the apical bone defect, with 3 months. (O, P) Clinical situation prior to abutment con-
demineralized bovine bone matrix with collagen. (D) nection. Insertion of an implant-supported provisional
Sutured punch graft to the host soft-tissue margin of the crown (Q, R), allowing for soft-tissue conditioning of the
extraction socket. (E, F) Clinical situation, 7 months later, peri-implant mucosa (S, T). (U, V) A screw-retained all-
showing a partially maintained soft contour. (G, H) Flap ceramic crown was inserted, showing an esthetically pleas-
elevation revealing well-regenerated bone in the entire ing result with a harmonious soft-tissue appearance.
area except for some fibrous tissue distocoronally. (I, J)

8
Alveolar ridge preservation in the esthetic zone

Clinical concept for hard- and soft-tissue gingival margin of the contralateral tooth (Fig. 4). In
preservation (socket seal technique) with order to compensate for this slight soft-tissue defi-
a hard-tissue substitute and an ciency, it was decided to harvest an autogenous graft
autogenous soft-tissue graft from the palate to seal the extraction socket. After
atraumatic tooth extraction it became obvious that
A 24-year-old male medical student attended with
tooth #11 had a long root fracture. After gentle clean-
pain at his central right incisor, tooth #11. The clinical ing of the granulation tissue at the apex of #12, the
assessment demonstrated buccal fistulae; however,
extraction socket, including the apical bone defect,
without increased pocket depth. Cone beam com-
was filled with demineralized bovine bone matrix
puted tomography revealed a large apical and
with collagen up to the level of the palatal bone. After
pararadicular radiolucency involving also the apex of
harvesting the autogenous punch graft from the
tooth #12 but with intact vitality. The buccal bone palate (21) the graft was meticulously sutured to the
plate seemed to be partially intact, at least in the
host soft-tissue margin. The postoperative regime
coronal part. As the patient was taking his course
was the same as described in the section ‘Soft-tissue
examinations at this time-point he was not ready for
preservation techniques’. Seven months later the soft
implant placement. Therefore, implant placement
contour was partially maintained and implant place-
was not possible within the next 0–2 months and an
ment was indicated. The open flap approach revealed
alveolar ridge preservation procedure was indicated.
very well-regenerated bone regeneration of the entire
The level of the soft-tissue margin af tooth #11 before
area, except for some fibrous tissue distocoronally
tooth extraction was more apical compared with the

A B C D

E F G H

I J K L

M N

Fig. 5. (A) Buccal fistula of tooth #11 with a probing depth and covered with a collagen membrane. (H, I) A palatal
of 10 mm at the buccal aspect. (B) X-ray showing extensive pedicle flap was prepared in order to close the orifice of the
root-canal treatment. The diagnosis was a vertical root extraction socket. Following a healing period of 6 months
fracture of tooth #11 after trauma. (C, D) Open flap access (J), the implant could be inserted without any further inter-
to extract the tooth. (E–G) Augmentation of the buccal bone vention (K, L) and was left to heal transmucosally (M). (N)
contour using a demineralized bovine bone matrix material Clinical situation with a screw-retained porcelain-fused-to-
mixed with autogenous bone from the surrounding tissue metal crown.

9
Jung et al.

that was removed before implant insertion. Bearing extraction, no alveolar ridge preservation is indicated.
in mind the large bone defect at the time of tooth The only exceptions are cases with soft-tissue defects
extraction, the socket seal technique was considered at the time of tooth extraction, in which a soft-tissue
to be very effective for facilitating implant placement preservation technique can improve the soft tissues.
in the correct prosthetically oriented position. Again, In all other cases where implant placement is not
this described technique did not allow for 100% possible or not indicated 0–2 months after tooth
maintenance of the buccal contour, and therefore extraction, alveolar ridge preservation procedures
augmentation of the buccal contour with demineral- should considered.
ized bovine bone matrix collagen and a collagen
membrane was performed. The implant was left for
3 months to allow submucosal healing and then Acknowledgments
abutment connection was performed. After soft-tis-
sue conditioning of the peri-implant mucosa, a The work on this review was funded by the Clinic of
screw-retained all-ceramic crown was inserted. The Fixed and Removable Prosthodontics and Dental
final clinical picture presents an esthetically pleasing Material Science, University of Zurich, Zurich,
result with a harmonious soft-tissue appearance. Switzerland.

Clinical concept for hard-tissue


preservation using a guided bone
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