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EDITOR’s OPINION
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Extraction socket preservation
Young-Kyun Kim, DDS, PhD
1,2,
, Jeong-Kui Ku, DDS, PhD, FIBCOMS
4, 1
Editor-in-Chief of J Korean Assoc Oral Maxillofac Surg,
2
Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul
National University Bundang Hospital, Seongnam,
3
Department of Dentistry & Dental Research Institute, School of Dentistry, Seoul
National University, Seoul,
4
Section Editor of J Korean Assoc Oral Maxillofac Surg,
5
Department of Oral and Maxillofacial Surgery,
Section of Dentistry, Armed Forces Capital Hospital, Armed Forces Medical Command, Seongnam, Korea
Abstract (J Korean Assoc Oral Maxillofac Surg 2020;46:435-439)
Extraction socket preservation (ESP) is widely performed after tooth extraction for future implant placement. For successful outcome of implants after
extractions, clinicians should be acquainted with the principles and indications of ESP. It is recommended that ESP be actively implemented in cases of
esthetic areas, severe bone defects, and delayed implant placement. Dental implant placement is recommended at least 4 months after ESP.
Key words: Dental implant, Tooth extraction, Socket graft
[paper submitted 2020. 11. 10 / accepted 2020. 11. 10]
Copyright© 2020 The Korean Association of Oral and Maxillofacial Surgeons. All rights reserved.
doi/10.5125/jkaoms.2020.46.6. pISSN 2234-7550 · eISSN 2234-
I. Introduction
Tooth extraction triggers disuse atrophy of the surrounding
alveolar bone. Within 1 year of extraction, an average of 50%
of the ridge width is reduced. The average amount of loss was
between 5-7 mm, and 2/3 of this reduction occurred within the
first 3 months and showed similar patterns in all areas of the
oral cavity
1
. Since maxillary buccal cortical bone resorption
occurs after extraction, the center of maxillary ridge is moved
toward the palatal side. Maxillary buccal resorption is more
pronounced in molars compared to anterior and premolar ar-
eas, and mandibular buccal resorption occurs more frequently
than that of the lingual bone 2. In 2009, a systemic review dem-
onstrated bone resorption of approximately 3 mm and 1.
mm horizontally and vertically, respectively, during the first
three months after extraction
3
. In 2012, another randomized
controlled trial revealed that more than 60% of the total re-
sorption occurred during the first six months after tooth loss 4.
Since disuse atrophy persists if not restored, many issues
with vertical and horizontal bone loss can occur. Additional
bone graft surgeries are inevitable for dental implant treat-
ment in areas of bone loss. To minimize bone loss, extraction
socket preservation (ESP) has been introduced, where bone
graft is performed at the time of extraction. However, the effi-
cacy of ESP has been controversial, and the procedure might
be unnecessary in some cases. At the time of extraction, the
clinician should make a decision based on the condition of
the extraction socket and surrounding tissues 5. Extraction
sockets can be classified into four types according to degree
of bone loss, on which need for ESP can depend.(Table 1)
Alveolar ridge preservation and post-extraction preservation
of the socket are used synonymously with ESP6,7.
II. Controversy regarding ESP
1. Positive view
Since ESP is performed to minimize ridge atrophy after
tooth extraction, several advantages have been suggested,
including that ESP reduces the need for additional bone graft,
facilitates the implant procedure, and improves marginal
bone loss and survival/success rate of implants 8. Avila-Ortiz
et al.
9
reported that the ESP group had statistically signifi-
cantly less bone resorption of 1 mm horizontally, 2 mm
Young-Kyun Kim Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang- gu, Seongnam 13620, Korea TEL: +82-31-787-7541 FAX: +82-31-787- E-mail: kyk0505@snubh ORCID: orcid/0000-0002-7268-
J Korean Assoc Oral Maxillofac Surg 2020;46:435-
at labial side and 1 mm at lingual side vertically compared
to the simple extraction group. In particular, the result of ESP
was excellent in the maxilla. When ESP is performed in the
maxillary posterior region, sinus elevation surgery can be
minimized or avoided, enabling flapless implant surgery
10
.
Natural bone healing is insufficient in extraction sockets
with periodontal or inflammatory disease because soft tissue
invasion into the socket impedes bone healing even long after
the procedure. To maintain the volume of the extraction sock-
et, thickness of the buccal bone wall is the most important
factor. ESP is generally recommended for sockets with thin
buccal bone wall (≤1 mm) to compensate for bone resorption
with suggested non-absorbable bone substitutes such as de-
proteinized bovine bone and alloplastic bone
11-
.
2. Negative view
Some researchers have argued a negative view of ESP
8,14,
.
ESP can reduce the bone resorption, but not completely pre-
vent. Rather, bone substitutes could contribute to impaired
natural bone healing. No differences has been reported in
feasibility, success/survival rates, and marginal bone loss
between implants with and without ESP
8,14,
. Simon et al.
16
questioned the usefulness of performing bone graft before
implant placement (guided bone regeneration [GBR], ESP)
and observed that bone height loss occurred more than bone
width even after bone graft. Therefore, it was argued that fill-
ing the graft material not only inside the extraction socket but
also outside the extraction socket and covering it with a bar-
rier membrane could prevent bone loss as much as possible.
III. Surgical Technique of ESP
Complete removal of inflammatory tissue and pathologic
lesions should be performed with minimally invasive proce-
dures after tooth extraction. All soft tissues along the socket
wall are removed, and spontaneous bleeding is induced to
release healing factors from the bone marrow. Suturing is per-
formed with a collagen plug, barrier membrane, or autogenous
gingival tissue after application of bone substitute. Primary
wound closure is not essential if proper suturing is achieved
to prevent dislodgement of the membrane or collagen plug
above the substitutes. It was said that using a osteoconductive
bone substitutes such as deproteinized bovine bone material
(DBBM) (Bio-Oss; Geistlich Pharma AG, Wolhusen, Swit-
zerland) or other synthetic materials with slow resorption and
covering the upper part with a resorbable barrier membrane
or connective tissue (CT) graft, or selecting the BioCol pro-
cedure maintains the volume of the extraction socket well and
facilitates implant placement in the future
5
. Implants were
placed with no complications at 4-6 months after grafting.
IV. Bone Graft Materials
1. Autogenous bone
In 2005, an ESP case with autogenous bone was reported
using the buccal bone of the maxillary canine and raising a
rotated palatal flap
17
. However, autogenous bone has not been
widely used due to its high risk of resorption.
2. Xenogeneic bone
Currently, xenografts are generally used in implant dentist-
ry including anorganic bovine bone and porcine bone. Artzi
et al.
18
reported 82% extraction socket filling with new
bone at 9 months after ESP using porous bovine bone min-
eral (PBBM). PBBM is a biocompatible and acceptable bone
substitute for ESP that shows no resorption for 9 months
19
. In
2018, deproteinized porcine bone mineral (DPBM) exhibited
comparable ESP outcomes with DBBM
20
.
3. Synthetic bone
Several synthetic bone products have been reported to have
effective outcomes on ESP, including Bioplant HTR
9,
, hy-
droxyapatite (HA)
22
, biphasic calcium phosphate (BCP)
23,
,
bioactive glass
25
, and calcium sulfate
25
.
4. Allogeneic bone
Allogeneic bone, such as freeze-dried bone allograft, has
been widely used in implant dentistry
26
. To improve the bone
healing potential and reduce the mobility of bone graft, allo-
Table 1. Classification of extraction sockets6, Class Description I 4-wall defect, intact bony housing, no wall involvement II 3-wall defect, 3 intact walls, 1 wall with dehiscence or fenestration III Type 1: adequate height, inadequate width Type 2: 2 intact walls, 2 walls with dehiscence or fenestration IV 1-wall defect, inadequate vertical height, inadequate horiz ontal width Young-Kyun Kim et al: Extraction socket preservation. J Korean Assoc Oral Maxillofac Surg 2020
J Korean Assoc Oral Maxillofac Surg 2020;46:435-
Jeong-Kui Ku,orcid/0000-0003-1192-
Authors’ Contributions
Y.K. participated in the literature review and wrote the
primary manuscript. J.K. participated in the literature re-
view and wrote the final manuscript.
Conflict of Interest
No potential conflict of interest relevant to this article was
reported.
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How to cite this article: Kim YK, Ku JK. Extraction socket pres- ervation. J Korean Assoc Oral Maxillofac Surg 2020;46:435-439. doi/10.5125/jkaoms.2020.46.6.
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