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1.  Ridge Preservation for Implant Therapy: a Review of the Literature 
Healing of the extraction socket after tooth removal involves retention of the blood clot followed by a sequence of events that lead to changes in the alveolar process in a three dimensional fashion. This normal healing event results in a minimal loss of vertical height (around 1 mm), but a substantial loss of width in the buccal-lingual plane (4-6 mm). During the first three months following extraction that loss has been shown to be significant and may result in both a hard tissue and soft tissue deformity affecting the ability to restore the site with acceptable esthetics. Procedures that reduce the resorptive process have been shown to be predictable and potentially capable of eliminating secondary surgery for site preparation when implant therapy is planned. The key element is prior planning by the dental therapist to act at the time of extraction to prevent the collapse of the ridge due to the loss of the alveolus.
Several techniques have been employed as ridge preservation procedures involving the use of bone grafts, barrier membranes and biologics to provide a better restorative outcome. This review will explore the evidence behind each technique and their efficacy in accomplishing site preparation. The literature does not identify a single technique as superior to others; however, all accepted therapeutic procedures for ridge preservation have been shown to be more effective than blood clot alone in randomized controlled studies.
PMCID: PMC4040934  PMID: 24893595
Bone grafts; guided bone regeneration; guided tissue regeneration; implant site preparation; ridge preservation.
2.  Simplified type 3 implant placement, after alveolar ridge preservation: a case study 
Oral & Implantology  2015;7(3):80-85.
Alveolar ridge, after tooth extraction, could reduce its volume up to 50% in buccal-lingual width in the first twelve months and residual dimensions could interfere with correct three dimensional placement of implants and influence negatively treatment outcomes with regard to function and aesthetic aspects.
Over the last decades, several approaches have been proposed and tested in order to prevent ridge volumetric contraction and provide maximum bone availability for implant procedure.
This article presents a case study with a single anterior tooth replacement, illustrating socket seal technique followed by a type 3 timing implant placement.
Immediately after tooth extraction, residual socket was grafted using Deproteinized Bovine Bone Mineral and a free gingival punch harvested from palate. After 3 months, a root-form titanium implant was inserted without additional regenerative procedures. Follow-up examination revealed favourable preservation of soft tissue width and height in the aesthetic area.
Socket seal approach maximizes soft tissue healing, preserving ridge envelope and the subsequent implant placement, furthermore, results simplified, as any augmentation techniques are required.
Clinical advantages of this method include predictable preservation of the soft tissues, favourable healing features, easy handling of graft materials and a positive benefit-cost ratio.
PMCID: PMC4402685  PMID: 25992262
socket preservation; ridge preservation; gbr
3.  Anterior maxillary defect reconstruction with a staged bilateral rotated palatal graft 
In the anterior maxilla, hard and soft tissue augmentations are sometimes required to meet esthetic and functional demands. In such cases, primary soft tissue closure after bone grafting procedures is indispensable for a successful outcome. This report describes a simple method for soft tissue coverage of a guided bone regeneration (GBR) site using the double-rotated palatal subepithelial connective tissue graft (RPSCTG) technique for a maxillary anterior defect.
We present a 60-year-old man with a defect in the anterior maxilla requiring hard and soft tissue augmentations. The bone graft materials were filled above the alveolar defect and a titanium-reinforced nonresorbable membrane was placed to cover the graft materials. We used the RPSCTG technique to achieve primary soft tissue closure over the graft materials and the barrier membrane. Additional soft tissue augmentation using a contralateral RPSCTG and membrane removal were simultaneously performed 7 weeks after the stage 1 surgery to establish more abundant soft tissue architecture.
Flap necrosis occurred after the stage 1 surgery. Signs of infection or suppuration were not observed in the donor or recipient sites after the stage 2 surgery. These procedures enhanced the alveolar ridge volume, increased the amount of keratinized tissue, and improved the esthetic profile for restorative treatment.
The use of RPSCTG could assist the soft tissue closure of the GBR sites because it provides sufficient soft tissue thickness, an ample vascular supply, protection of anatomical structures, and patient comfort. The treatment outcome was acceptable, despite membrane exposure, and the RPSCTG allowed for vitalization and harmonization with the recipient tissue.
Graphical Abstract
PMCID: PMC4050232  PMID: 24921059
Alveolar ridge augmentation; Guided tissue regeneration; Palate; Surgical flaps
4.  Newly forming bone graft: a novel surgical approach to the treatment of denuded roots 
Journal of Applied Oral Science  2012;20(3):392-398.
Many techniques have been proposed for root coverage. However, none of them presents predictable results in deep and wide recessions
The aim of this case series report is to describe an alternative technique for root coverage at sites showing deep recessions and attachment loss >4 mm at buccal sites.
Material and Methods
Four patients presenting deep recession defects at buccal sites (≥4 mm) were treated by the newly forming bone graft technique, which consists in the creation of an alveolar socket at edentulous ridge and transferring of granulation tissue present in this socket to the recession defect after 21 days. Clinical periodontal parameters, including recession depth (RD), probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), plaque index (PI) and keratinized gingiva width (KGW) were evaluated by a single examiner immediately before surgery and at 1, 3, 6 and 9 months postoperatively.
All cases showed reduction in RD and PD, along with CAL gain, although no increase in KGW could be observed. These findings suggest that the technique could favor periodontal regeneration along with root coverage, especially in areas showing deep recessions and attachment loss.
PMCID: PMC3881776  PMID: 22858709
Gingival recession; Guided tissue regeneration; Citric acid; Grafts
5.  Single-Tooth Morse Taper Connection Implant Placed in Grafted Site of the Anterior Maxilla: Clinical and Radiographic Evaluation 
Case Reports in Dentistry  2014;2014:183872.
The aim of this study was to achieve aesthetically pleasing soft tissue contours in a severely compromised tooth in the anterior region of the maxilla. For a right-maxillary central incisor with localized advanced chronic periodontitis a tooth extraction followed by reconstructive procedures and delayed implant placement was proposed and accepted by the patient. Guided bone regeneration (GBR) technique was employed, with a biphasic calcium-phosphate (BCP) block graft placed in the extraction socket in conjunction with granules of the same material and a resorbable barrier membrane. After 6 months of healing, an implant was installed. The acrylic provisional restoration remained in situ for 3 months and then was substituted with the definitive crown. This ridge reconstruction technique enabled preserving both hard and soft tissues and counteracting vertical and horizontal bone resorption after tooth extraction and allowed for an ideal three-dimensional implant placement. Localized severe alveolar bone resorption of the anterior maxilla associated with chronic periodontal disease can be successfully treated by means of ridge reconstruction with GBR and delayed implant insertion; the placement of an early-loaded, Morse taper connection implant in the grafted site was effective to create an excellent clinical aesthetic result and to maintain it along time.
PMCID: PMC4238176  PMID: 25431687
6.  Clinical and biometrical evaluation of socket preservation using demineralized freeze-dried bone allograft with and without the palatal connective tissue as a biologic membrane 
Dental Research Journal  2012;9(6):758-763.
Alveolar ridge preservation following tooth extraction has the ability to maintain the ridge dimensions and allow the implant placement in an ideal position fulfilling both functional and aesthetic results. The aim of this study was to evaluate the efficacy of the palatal connective tissue as a biological membrane for socket preservation with demineralized freeze-dried bone allograft (DFDBA).
Materials and Methods:
Twelve extraction sites were treated with DFDBA with (case group) and without (control group) using autogenous palatal connective tissue membrane before placement of implants. Alveolar width and height, amount of keratinized tissue, and gingival level were measured at pre-determined points using a surgical stent at two times, the time of socket preservation surgery
In both groups a decrease in all socket dimensions was found. The average decrease in socket width, height, keratinized tissue, and gingival level in case group was 1.16, 0.72, 3.58, and 1.27 mm, and in control group was 2.08, 0.86, 4.52, and 1.58 mm respectively. Statistical analysis showed that decrease in socket width (P = 0.012), keratinized tissue (P ≤ 0.001), and gingival level (P = 0.031) in case group was significantly lower than that of the control group. Results showed no meaningful difference in socket height changes when compared with case and control groups (P = 0.148).
Under the limits of this study, connective tissue membrane could preserve socket width, amount of keratinized tissue, and the gingival level more effectively than DFDBA alone.
PMCID: PMC3612227  PMID: 23559955
Connective tissue; dental implant; membrane; tooth socket
7.  Socket preservation using deproteinized horse-derived bone mineral 
The healing process following tooth extraction apparently results in a pronounced resorption of the alveolar ridge. As a result, the width of alveolar ridge is reduced and severe alveolar bone resorption occurs. The purpose of this experiment is to clinically and histologically evaluate the results of using horse-derived bone mineral for socket preservation.
The study comprised 4 patients who were scheduled for extraction as a consequence of severe chronic periodontitis or apical lesion. The extraction was followed by socket preservation using horse-derived bone minerals. Clinical parameters included buccal-palatal width, mid-buccal crest height, and mid-palatal crest height. A histologic examination was conducted.
The surgical sites healed uneventfully. The mean ridge width was 7.75 ± 2.75 mm at baseline and 7.00 ± 2.45 mm at 6 months. The ridge width exhibited no significant difference between baseline and 6 months. The mean buccal crest height at baseline was 7.5 ± 5.20 mm, and at 6 months, 3.50 ± 0.58 mm. The mean palatal crest height at baseline was 7.75 ± 3.10 mm, and at 6 months, 5.00 ± 0.82 mm. There were no significant differences between baseline and 6 months regarding buccal and palatal crest heights. The amount of newly formed bone was 9.88 ± 2.90%, the amount of graft particles was 42.62 ± 6.57%, and the amount of soft tissue was 47.50 ± 9.28%.
Socket preservation using horse-derived bone mineral can effectively maintain ridge dimensions following tooth extraction and can promote new bone formation through osteoconductive activities.
PMCID: PMC2967810  PMID: 21072219
Bone resorption; Bone substitutes; Clinical trial; Tooth socket
8.  Peri-implant soft tissue management: Where are we? 
Dental implants have evolved dramatically over the last decade, and so have our expectations from them in terms of functional and esthetic criteria. The maintenance and augmentation of the soft tissue has emerged as an area of concern and focus. The triad of anatomical peri-implant characteristics, soft tissue response to the implant material, and clinical skill form the fundamental principles in augmenting soft tissue. However, as clinicians, where are we with regards to the ability to augment and maintain soft tissue around dental implants, about 40 years after the first implants were placed? We now understand that peri-implant soft tissue management begins with extraction management. Our treatment modalities have evolved from socket compression post-extraction, to socket preservation with an aim to enhance the eventual peri-implant soft tissue. This short communication will assess the evolution of our thought regarding peri-implant soft tissue management, augmentation of keratinized mucosa around implants, and also look at some recent techniques including the rotated pedicle connective tissue graft for enhancing inter-implant papilla architecture. With newer research modalities, such as cyto-detachment technology, and cutting-edge bioengineering solutions (possibly a soft-tissue-implant construct) which might be available in the near future for enhancing soft tissue, we are certainly in an exciting era in dentistry.
PMCID: PMC3590740  PMID: 23493178
Dental implant; dental implantology; graft; grafting; tissue
9.  Determination of orthodontic tooth movement and tissue reaction following demineralized freeze-dried bone allograft grafting intervention 
Dental Research Journal  2012;9(2):203-208.
Socket preservation after tooth extraction is one of the indications of bone grafting to enhance preorthodontic condition. The aim of this study is to determine the effects of socket preservation on the immediate tooth movement, alveolar ridge height preservation and orthodontic root resorption.
Materials and Methods:
In a split-mouth technique, twelve sites in three dogs were investigated as an experimental study. Crushed demineralized freeze-dried bone allograft (DFDBA) (CenoBone®) was used as the graft material. The defects were made by the extraction of 3rd premolar. On one side of each jaw, the defects were preserved by DFDBA and defects of the other side left opened as the control group. Simultaneously the teeth adjacent to the defects were pulled together by a NiTi coil spring. After eight weeks, the amount of (OTM), alveolar height, and root resorption were measured. Analysis of variance was used for purpose of comparison.
There was a slight increase in OTM at grafted sites as they were compared to the control sites (P<0.05). Also a significant bone resorption in control site and successful socket preservation in experimental site were observed. Reduction of root resorption at the augmented site was significant compared to the normal healing site (P<0.05).
Using socket preservation, tooth movement can be immediately started without waiting for the healing of the recipient site. This can provide some advantages like enhanced rate of OTM, its approved effects on ridge preservation that reduces the chance of dehiscence and the reduction of root resorption.
PMCID: PMC3353699  PMID: 22623939
Demineralized freeze-dried bone allograft; orthodontic tooth movement; root resorption; socket preservation
10.  Autologous Platelet Rich Plasma After Third Molar Surgery: A Comparative Study 
This study is an attempt to evaluate the use of autologous platelet rich plasma (PRP) to promote wound healing and osseous regeneration in human third molar extraction sockets.
Materials and method
PRP was prepared after two centrifugation and the gelling agent used was freshly prepared 10% calcium chloride.PRP gel was placed in one of the extracted sockets of bilateral impacted mandibular third molars. IOPA Xrays were used to evaluate the wound dehiscence, probing depth, bone density & alveolar bone level after 1st, 2nd and 7th day and 3rd & 6th month respectively.
On evaluation, it was found that PRP grafted sockets showed dehiscence in 8% cases. The decrease in alveolar bone level was highly significant in PRP grafted sockets in 3rd and 6th month post operatively. There was significant difference between pre-operative density of adjacent bone and bone formed in extraction sockets at 3rd and 6th month in PRP grafted sockets. There was significant reduction in probing depth from initial period to 3 and 6 months in both the groups, but PRP grafted sockets showed greater decrease in probing depth.
PRP is an inexpensive and widely available modality to minimize postoperative complication and enhance both hard and soft tissue healing potentials. This autologous product eliminates concern about immunogenic reaction and disease transmission. Its beneficial outcomes in dental clinic, including decrease in bleeding and rapid wound healing hold promise for further procedures.PRP is thus a new application in tissue engineering and developing area for clinician and researchers.
PMCID: PMC3386415  PMID: 23730070
Autologous; Growth factors; Platelet-rich plasma; Bone density; Soft tissue healing
11.  Soft tissue expansion before vertical ridge augmentation: Inflatable silicone balloons or self-filling osmotic tissue expanders? 
Recent advances in periodontal plastic surgical procedures allow the clinician to reconstruct deficient alveolar ridges in more predictable ways than previously possible. Placement of implant/s in resorbed ridges poses numerous challenges to the clinician for successful esthetic and functional rehabilitation. The reconstruction frequently utilizes one or combination of periodontal plastic surgical procedures in conjunction with autogenous bone grafting, allogenic bone block grafting, ridge split techniques, distraction osteogenesis, or guided bone regeneration (GBR) for most predictable outcomes. Current surgical modalities used in reconstruction of alveolar ridge (horizontal and/or vertical component) often involve the need of flap transfer. Moreover, there is compromise in tissue integrity and color match owing to different surgical site and the tissue utilized is insufficient in quantity leading to post surgical graft exposition and/or loss of grafted bone. Soft tissue expansion (STE) by implantation of inflatable silicone balloon or self filling osmotic tissue expanders before reconstructive surgery can overcome these disadvantages and certainly holds a promise for effective method for generation of soft tissue thereby achieving predictable augmentation of deficient alveolar ridges for the implant success. This article focuses and compares these distinct tissue expanders for their clinical efficacy of achieving excess tissue that predominantly seems to be prerequisite for ridge augmentation which can be reasonably followed by successful placement of endosseous fixtures.
PMCID: PMC4158582  PMID: 25210255
Alveolar ridge reconstruction; bone grafts; controlled tissue expansion; dental implants; soft tissue expansion; systematic review
12.  Alveolar ridge preservation of an extraction socket using autogenous tooth bone graft material for implant site development: prospective case series 
This case series evaluated the clinical efficacy of autogenous tooth bone graft material (AutoBT) in alveolar ridge preservation of an extraction socket. Thirteen patients who received extraction socket graft using AutoBT followed by delayed implant placements from Nov. 2008 to Aug. 2010 were evaluated. A total of fifteen implants were placed. The primary and secondary stability of the placed implants were an average of 58 ISQ and 77.9 ISQ, respectively. The average amount of crestal bone loss around the implant was 0.05 mm during an average of 22.5 months (from 12 to 34 months) of functional loading. Newly formed tissues were evident from the 3-month specimen. Within the limitations of this case, autogenous tooth bone graft material can be a favorable bone substitute for extraction socket graft due to its good bone remodeling and osteoconductivity.
PMCID: PMC4279052  PMID: 25551013
Transplantation; Autologous; Extraction socket; Dental implants; Bone substitutes
13.  Dimensional Ridge Preservation with a Novel Highly Porous TiO2 Scaffold: An Experimental Study in Minipigs 
Despite being considered noncritical size defects, extraction sockets often require the use of bone grafts or bone graft substitutes in order to facilitate a stable implant site with an aesthetically pleasing mucosal architecture and prosthetic reconstruction. In the present study, the effect of novel TiO2 scaffolds on dimensional ridge preservation was evaluated following their placement into surgically modified extraction sockets in the premolar region of minipig mandibles. After six weeks of healing, the scaffolds were wellintegrated in the alveolar bone, and the convex shape of the alveolar crest was preserved. The scaffolds were found to partially preserve the dimensions of the native buccal and lingual bone walls adjacent to the defect site. A tendency towards more pronounced vertical ridge resorption, particularly in the buccal bone wall of the nongrafted alveoli, indicates that the TiO2 scaffold may be used for suppressing the loss of bone that normally follows tooth extraction.
PMCID: PMC3469108  PMID: 23091493
14.  Long palatal connective tissue rolled pedicle graft with demineralized freeze-dried bone allograft plus platelet-rich fibrin combination: A novel technique for ridge augmentation - Three case reports 
Replacement of missing maxillary anterior tooth with localized residual alveolar ridge defect is challenging, considering the high esthetic demand. Various soft and hard tissue procedures were proposed to correct alveolar ridge deformities. Novel techniques have evolved in treating these ridge defects to improve function and esthetics. In the present case reports, a novel technique using long palatal connective tissue rolled pedicle graft with demineralized freeze-dried bone allografts (DFDBAs) plus Platelet-rich fibrin (PRF) combination was proposed to correct the Class III localized anterior maxillary anterior alveolar ridge defect. The present technique resulted in predictable ridge augmentation, which can be attributed to the soft and hard tissue augmentation with a connective tissue pedicle and DFDBA plus PRF combination. This technique suggests a variation in roll technique with DFDBA plus PRF and appears to promise in gaining predictable volume in the residual ridge defect and can be considered for the treatment of moderate to severe maxillary anterior ridge defects.
PMCID: PMC4439638  PMID: 26015679
Demineralized freeze-dried bone allografts; localized residual ridge defect; roll pedicle graft platelet-rich fibrin
15.  Evaluating the clinical and esthetic outcome of apically positioned flap technique in augmentation of keratinized gingiva around dental implants 
Contemporary Clinical Dentistry  2013;4(3):319-324.
Dental implants though a successful treatment modality there exists controversies regarding the relationship between the adequacy of the keratinized gingiva (KG) and peri-implant health. The presence of an adequate amount of peri-implant KG reduces gingival inflammation and hence soft-tissue augmentation should be frequently considered. Among the various periodontal plastic surgical procedures, the apically displaced flap increases the width of keratinized tissue with reduced patient morbidity. The current study aims at evaluating the esthetic improvement in KG around dental implants applying apically positioned flap (APF) technique.
Materials and Methods:
A total of 10 endosseous dental implants were placed in eight systemically healthy patients. APF surgery was performed at the implant site on the buccal aspect either at the time of implant placement (one stage surgical protocol) or during the implant recovery stage (two stage surgical protocols) for increasing the width of KG and reviewed until 12 weeks post-operatively. The width of KG was evaluated at baseline and at the end of 12 weeks after surgery. Paired t-test was performed to evaluate the changes in the width of KG at baseline and at 12 weeks post-operatively. In addition, soft-tissue esthetic outcome was assessed by using visual analog scale (VAS).
The mean width of KG at baseline was 1.47 mm and 12 weeks post-operatively was 5.42 mm. The gain in KG from baseline was 3.95 mm with the P value of 0.000, which was highly statistically significant. The assessment of esthetic outcome using VAS gave an average score of 7.1 indicating good esthetics.
The technique of APF yielded a significant improvement in keratinized tissue, which is both functionally and esthetically acceptable.
PMCID: PMC3793552  PMID: 24124297
Dental esthetics; dental implants; flap; gingiva
16.  Alveolar Ridge Preservation Using Leukocyte and Platelet-Rich Fibrin: A Report of a Case 
Case Reports in Dentistry  2011;2011:345048.
In order for a dental implant to be restored optimally, it must be placed in an ideal anatomic position. However, this is not always possible, since physiological wound healing after tooth removal, often results in hard and soft tissue changes which ultimately compromises ideal implant placement. With the aim of minimising the need for tissue augmentation, several alveolar ridge preservation (ARP) techniques have been developed. These often require the use of grafting material and therefore increase the risk of disease transmission. Leukocyte and platelet-rich fibrin (L-PRF) is a newly developed platelet concentrate that is prepared from the patient's own blood. Clinical research has indicated that it improves wound healing and stimulates bone formation. We present a case where L-PRF was successfully used in an ARP procedure to facilitate implant placement in a compromised extraction socket.
PMCID: PMC3335652  PMID: 22567435
17.  Remnant-Preserving Anterior Cruciate Ligament Reconstruction Using a Three-Dimensional Fluoroscopic Navigation System 
Knee Surgery & Related Research  2014;26(3):168-176.
Recently, remnant-preserving anterior cruciate ligament (ACL) reconstruction has been increasingly performed to achieve revascularization, cell proliferation, and recovery of high-quality proprioception. However, poor arthroscopic visualization makes accurate socket placement during remnant-preserving ACL reconstruction difficult. This study describes a surgical technique used to create an anatomical femoral socket with a three-dimensional (3D) fluoroscopy based navigation system during technically demanding remnant-preserving ACL reconstruction.
Surgical Technique
After a reference frame was attached to the femur, an intraoperative image of the distal femur was obtained, transferred to the navigation system and reconstructed into a 3D image. A navigation computer helped the surgeon visualize the entire lateral wall of the femoral notch and lateral intercondylar ridge, even when the remnant of the ruptured ACL impeded arthroscopic visualization of the bone surface. When a guide was placed, the virtual femoral tunnel overlapped the reconstructed 3D image in real time; therefore, only minimal soft tissue debridement was required.
Materials and Methods
We treated 47 patients with remnant-preserving ACL reconstruction using this system. The center of the femoral socket aperture was calculated according to the quadrant technique using 3D computed tomography imaging.
The femoral socket locations were considered to be an anatomical footprint in accordance with previous cadaveric studies.
The 3D fluoroscopy-based navigation can assist surgeons in creating anatomical femoral sockets during remnant-preserving ACL reconstruction.
PMCID: PMC4163575  PMID: 25229047
Anterior cruciate ligament; Remnant; Computer-assisted surgery; Three-dimensional computed tomography
18.  Secondary closure of an extraction socket using the double-membrane guided bone regeneration technique with immediate implant placement 
Immediate implantation presents challenges regarding site healing, osseointegration, and obtaining complete soft-tissue coverage of the extraction socket, especially in the posterior area. This last issue is addressed herein using the double-membrane (collagen membrane+high-density polytetrafluoroethylene [dPTFE] membrane) technique in two clinical cases of posterior immediate implant placement.
An implant was placed immediately after atraumatically extracting the maxillary posterior tooth. The gap between the coronal portion of the fixture and the adjacent bony walls was filled with allograft material. In addition, a collagen membrane (lower) and dPTFE membrane (upper) were placed in a layer-by-layer manner to enable the closure of the extraction socket without a primary flap closure, thus facilitating the preservation of keratinized mucosa. The upper dPTFE membrane was left exposed for 4 weeks, after which the membrane was gently removed using forceps without flap elevation.
There was considerable plaque deposition on the outer surface of the dPTFE membrane but not on the inner surface. Moreover, scanning electron microscopy of the removed membrane revealed only a small amount of bacteria on the inner surface of the membrane. The peri-implant tissue was favorable both clinically and radiographically after a conventional dental-implant healing period.
Secondary closure of the extraction socket and immediate guided bone regeneration using the double-membrane technique may produce a good clinical outcome after immediate placement of a dental implant in the posterior area.
PMCID: PMC3213237  PMID: 22087417
Bone regeneration; Dental implantation; Tooth socket
19.  Comparative analysis of use of porous orbital implant with mucus membrane graft and dermis fat graft as a primary procedure in reconstruction of severely contracted socket 
Indian Journal of Ophthalmology  2014;62(2):145-153.
The purpose of our study is to present a surgical technique of primary porous orbital ball implantation with overlying mucus membrane graft (MMG) for reconstruction of severely contracted socket and to evaluate prosthesis retention and motility in comparison to dermis fat graft (DFG).
Study Design:
Prospective comparative study.
Materials and Methods:
A total of 24 patients of severe socket contracture (Grade 2-4 Krishna's classification) were subdivided into two groups, 12 patients in each group. In Group I, DFG have been used for reconstruction. In Group II, porous polyethylene implant with MMG has been used as a primary procedure for socket reconstruction. In Group I DFG was carried out in usual procedure. In case of Group II, vascularized scar tissues were separated 360° and were fashioned into four strips. A scleral capped porous polyethylene implant was placed in the intraconal space and four strips of scar tissue were secured to the scleral cap and extended part overlapped the implant to make a twofold barrier between the implant and MMG. Patients were followed-up as per prefixed proforma. Prosthesis motility and retention between the two groups were measured.
In Group I, four patients had recurrence of contracture with fall out of prosthesis. In Group II stable reconstruction was achieved in all the patients. In terms of prosthesis motility, maximum in Group I was 39.2% and Group II, was 59.3%. The difference in prosthesis retention (P = 0.001) and motility (P = 0.004) between the two groups was significant.
Primary socket reconstruction with porous orbital implant and MMG for severe socket contracture is an effective method in terms of prosthesis motility and prosthesis retention.
PMCID: PMC4005228  PMID: 24618485
Contracted socket; dermis fat graft; porous orbital implant; reconstruction
20.  Clinical evaluation of the marginal gingiva as a donor tissue to augment the width of keratinized gingiva: Series of 2 cases with 3-year follow-up 
Contemporary Clinical Dentistry  2015;6(Suppl 1):S126-S128.
The indications to increase the width of keratinized gingiva have not been proven beyond doubt; however it becomes indispensable in certain clinical situations. Inspite of frequently encountered complications, palate is considered most preferred area to harvest the free gingival graft (FGG). This procedure aimed at investigating the potential of buccal marginal gingiva as a donor to augment keratinized gingiva. To the best of our knowledge, no such cases have been documented in the literature. FGG harvested from maxillary buccal marginal gingiva was used to augment gingiva in the mandibular anterior region for two patients. This not only improved plaque control but also resulted in acceptable esthetic results over 3 years. Furthermore, gingiva at donor sites gained its normal form and was in harmony with the neighboring teeth. It may be concluded that buccal marginal gingiva may provide a predictable substitute to other donor tissues to augment gingiva.
PMCID: PMC4374310  PMID: 25821366
Color; esthetics; free gingival grafts; keratinized tissue/surgery
21.  Postextraction Alveolar Ridge Preservation: Biological Basis and Treatments 
Following tooth extraction, the alveolar ridge undergoes an inevitable remodeling process that influences implant therapy of the edentulous area. Socket grafting is a commonly adopted therapy for the preservation of alveolar bone structures in combination or not with immediate implant placement although the biological bases lying behind this treatment modality are not fully understood and often misinterpreted. This review is intended to clarify the literature support to socket grafting in order to provide practitioners with valid tools to make a conscious decision of when and why to recommend this therapy.
PMCID: PMC3378971  PMID: 22737169
22.  Management of Radiation-induced Severe Anophthalmic Socket Contracture in Patients with Uveal Melanoma 
High-dose radiotherapy can cause contracture of the anophthalmic socket, but the incidence of this complication in patients with enucleation for uveal melanoma has not previously been reported. We reviewed the surgical management and outcomes in terms of successful prosthesis wear in patients with severe contracture of the anophthalmic socket treated with high-dose radiotherapy for high-risk uveal melanoma and estimated the relative risk of this complication.
The medical records of all consecutive patients enrolled in a prospective uveal-melanoma tissue-banking protocol at our institution who underwent enucleation between January 2003 and December 2010 were reviewed. Patients who underwent adjuvant radiotherapy of the enucleated socket were further studied.
Of the 68 patients enrolled in the prospective tissue banking protocol, 12 had high-risk histologic features (e.g., extrascleral spread or vortex vein invasion) and were treated with 60 Gy of external-beam radiotherapy after enucleation. Five of these patients (41.7%) experienced severe socket contracture precluding prosthesis wear. The median time to onset of contracture following completion of radiotherapy was 20 months. Three patients underwent surgery, which entailed scar tissue release, oral mucous membrane grafting, and socket reconstruction; 2 patients declined surgery. All 3 patients who had surgery experienced significant improvement of socket contracture that enabled patients to wear a prosthesis again.
High-dose radiotherapy after enucleation in patients with uveal melanoma caused severe socket contracture and inability to wear a prosthesis in approximately 40% of patients. Surgical repair of the contracted socket using oral mucous membrane grafting can allow resumption of prosthesis wear.
PMCID: PMC3359825  PMID: 22581085
23.  Various autogenous fresh demineralized tooth forms for alveolar socket preservation in anterior tooth extraction sites: a series of 4 cases 
The aim of this study was to evaluate the clinical relevance of autogenous fresh demineralized tooth (Auto-FDT) prepared at chairside immediately after extraction for socket preservation. Teeth were processed to graft materials in block, chip, or powder types immediately after extraction. Extraction sockets were filled with these materials and dental implants were installed immediately or after a delay. A panoramic radiograph and a conebeam CT were taken. In two cases, tissue samples were taken for histologic examination.
Vertical and horizontal maintenance of alveolar sockets showed some variance depending on the Auto-FDT and barrier membrane types used. Radiographs showed good bony healing. Histologic sections showed that it guided good new bone formation and resorption pattern of the Auto-FDT.
This case series shows that Auto-FDT prepared at chairside could be a good material for the preservation of extraction sockets. This study will suggest the possibility of recycling autogenous tooth after immediate extraction.
PMCID: PMC4559089  PMID: 26366388
Alveolar socket preservation; Bone regeneration; Biocompatible; Bone substitute; Autogenous demineralized tooth
24.  Soft tissue grafting to improve implant esthetics 
Dental implants are becoming the treatment of choice to replace missing teeth, especially if the adjacent teeth are free of restorations. When minimal bone width is present, implant placement becomes a challenge and often resulting in recession and dehiscence around the implant that leads to subsequent gingival recession. To correct such defect, the author turned to soft tissue autografting and allografting to correct a buccal dehiscence around tooth #24 after a malpositioned implant placed by a different surgeon. A 25-year-old woman presented with the chief complaint of gingival recession and exposure of implant threads around tooth #24. The patient received three soft tissue grafting procedures to augment the gingival tissue. The first surgery included a connective tissue graft to increase the width of the keratinized gingival tissue. The second surgery included the use of autografting (connective tissue graft) to coronally position the soft tissue and achieve implant coverage. The third and final surgery included the use of allografting material Alloderm to increase and mask the implant from showing through the gingiva. Healing period was uneventful for the patient. After three surgical procedures, it appears that soft tissue grafting has increased the width and height of the gingiva surrounding the implant. The accomplished thickness of gingival tissue appeared to mask the showing of implant threads through the gingival tissue and allowed for achieving the desired esthetic that the patient desired. The aim of the study is to present a clinical case with soft tissue grafting procedures.
PMCID: PMC3645463  PMID: 23662087
case report; connective tissue; dental implants; allograft; coronally positioned flap
25.  Differential expression of immunologic proteins in gingiva after socket preservation in mini pigs 
Journal of Applied Oral Science  2015;23(2):187-195.
During healing following tooth extraction, inflammation and the immune response within the extraction socket are related to bone resorption.
: We sought to identify how the alloplastic material used for socket preservation affects the immune responses and osteoclastic activity within extraction sockets.
Material and Methods
: Using a porcine model, we extracted teeth and grafted biphasic calcium phosphate into the extraction sockets. We then performed a peptide analysis with samples of gingival tissue from adjacent to the sockets and compared the extraction only (EO) and extraction with socket preservation (SP) groups. We also used real-time polymerase chain reaction (PCR) to evaluate the expression level of immunoglobulins, chemokines and other factors related to osteoclastogenesis. Differences between the groups were analyzed for statistical significance using paired t tests.
: Levels of IgM, IgG and IGL expression were higher in the EO group than in the SP group 1 week post-extraction, as were the levels of CCL3, CCL5, CXCL2, IFN-γ and TNF-α expression (p<0.05). In addition, receptor activator of nuclear factor kappa-B ligand (RANKL) was also significantly upregulated in the EO group (p<0.05), as were IL-1β, IL-6 and IL-8 (p<0.05).
: These results suggest that the beneficial effect of socket preservation can be explained by suppression of immune responses and inflammation.
PMCID: PMC4428464  PMID: 26018311
Tooth socket; Tooth extraction; Alveolar bone loss; Cytokines; Preprosthetic oral surgical procedures

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