Article
There cannot be many clinicians who, in the heat of the moment, while extracting a challenging tooth, have been less than gentle with both the soft tissues and the surrounding alveolar bone. The urgency of extracting the tooth is perhaps understandable in the heat of the moment, with less concern given to future replacement options. This approach can, however, have significant longer-term impact. The day will inevitably arrive where the clinician is faced with residual defects in the bone or soft tissue, which may limit treatment options and leave a complex reconstructive challenge, often leading to a compromise functionally and aesthetically.
Over the past two decades, patients (where they can access oral health care) have increasingly sought a reliable and aesthetic option for tooth replacement, with dental implants being seen by many patients and clinicians alike, as the gold standard for tooth replacement.
Effective implant treatment does rely on a healthy tissue foundation, leading to an increased awareness of the need for careful soft and hard tissue management at the time of extraction, and the investigation and use of a range of extraction instruments and grafting techniques to promote a favourable tissue profile. Research is also important to discover whether such techniques have significant benefits.1,2
Alveolar ridge preservation (ARP) procedures have been developed in parallel to implant treatment, under the assumption that they act to modify the socket healing process, promoting retention of the original bone and soft tissue topographical contour, while providing an adequate surgical foundation for the successful functional and aesthetic restoration of the patient.
The question being asked by many dentists today, is whether ARP is required, does it have a profound effect on implant outcomes, and do I have to offer it as a choice to patients during the consent process? Is the ability to minimize the damage to the socket alveolus when using periotomes, luxators and ultrasonic bone cutting instruments just as effective?
What we can all agree on is that after tooth extraction, dimensional and alveolar bone changes are unsurprisingly complex, and are affected by the surgical technique, traumatic injury, variations in presenting tooth pathology, differences in socket morphology, disparity in the patient's local gingival phenotype and specific systemic conditions. Even when choosing extraction techniques that minimize trauma to the alveolus, it is inevitable that the socket's bundle bone will be lost, with the ensuing dimensional change affected by the buccal socket thickness and the invasive nature of the procedure.3
ARP's ability to positively influence mucosal and alveolar healing characteristics has been extensively investigated, with different surgical techniques, bone grafting materials and barrier materials investigated. The outcomes from these trials are sometimes conflicting, but in general, demonstrate equivalent or improved levels of new bone formation and horizontal bone width, with significant improvements in vertical bone height, volumetric bone composition, healed mucosal topographical contour, and a reduced need for bone augmentation at 4-month healing. As patient treatment is diagnostic led, it is therefore imperative that dental professionals provide a full list of viable treatment options and actively discuss alternative care pathways, so that informed consent can be maintained.
The advantages of ARP procedures have been discussed by the European Federation of Periodontology,4,5 which outlined that ARP can produced a positive impact on socket healing and alveolar bone width. What was particularly important, was the need for dentists to evaluate the efficacy of different biomaterial grafting agents and coronal sealing techniques (coronally advanced flap/free gingival graft/connective tissue barrier) and their direct effect on limiting hard and soft tissue dimensional change.6
What we should now discuss with patients is that there is comprehensive evidence to demonstrate that ARP has undergone significant evaluation, is safe to use, is a validated for specific clinical situations and can provide clinicians with significant advantages, when considering their future treatment options.7
While much of this discussion may seem academic to the busy practitioner, who is focused on dealing with an increased number of patients attending with gross caries, the range of CPD articles in Dental Update has increasingly become essential reading as techniques advance. The circumstances and options where clinical care can be delivered expands daily, and keeping aware of developments and investing in lifelong learning has become increasingly important in an ever-increasing litigious society. Particularly when patients may argue ‘if I had been made aware a certain treatment option was available, I would have selected it, but I wasn't’!
As technology and techniques advance, keeping well-informed about new clinical techniques becomes more of a challenge. While AI may be a help, Dental Update remains a go to reference for all matters oral health care.