Alveolar ridge preservation with guided bone regeneration or socket seal technique. A randomised, single-blind controlled clinical trial

Abstract

Objectives: To compare radiographic bone changes, following alveolar ridge preservation (ARP) using Guided Bone Regeneration (GBR), a Socket Seal (SS) technique or unassisted socket healing (Control).

Material and methods: Patients requiring a single rooted tooth extraction in the anterior maxilla, were randomly allocated into: GBR, SS and Control groups (n= 14/). Cone Beam Computed Tomography (CBCT) images were recorded post-extraction and at 4 months, the mid-buccal and mid-palatal alveolar ridge heights (BARH/PARH) were measured. The alveolar ridge width, cross-sectional socket and alveolar-process area changes, implant placement feasibility, requirement for bone augmentation and post-surgical complications were also recorded.

Results: BARH and PARH was found to increase with the SS (0.65 mm ± 1.1/0.65 mm ± 1.42) techniques, stabilise with GBR (0.07 mm ± 0.83/0.86 mm ±1.37) and decrease in the Control (-0.52 mm ± 0.8/-0.43 mm ± 0.83). Statistically significance was found when comparing the GBR and SS BARH (p = .04/.005) and GBR PARH (p = .02) against the Control. GBR recorded the smallest reduction in alveolar ridge width (-2.17 mm ± 0.84), when compared to the Control (-2.3 mm ± 1.11) (p = .89). A mid-socket cross-sectional area reduction of 4% (-2.27 mm² ± 11.89), 1% (-0.88 mm² ± 15.48) and 13% (-6.93 mm² ± 8.22) was found with GBR, SS and Control groups (GBR vs. Control p = .01). The equivalent alveolar process area reduction was 8% (-7.36 mm² ± 10.45), 6% (-7 mm² ± 18.97) and 11% (-11.32 mm² ± 10.92). All groups supported implant placement, with bone dehiscence noted in 57% (n = 4), 64%(n = 7) and 85%(n = 12) of GBR, SS and Control cases (GBR vs. Control p = .03). GBR had a higher risk of swelling and mucosal colour change, with SS associated with graft sequestration and matrix breakdown.

Conclusion: GBR ARP was found to be more effective at reducing radiographic bone dimensional changes following tooth extraction.

Keywords: alveolar bone dimensions; alveolar ridge preservation; bone healing complications and visual analogue pain scores; cone beam computerised tomography; guided bone regeneration; optical scanning; randomised controlled trial; socket seal.

FIGURE 1

Photographs demonstrating Surgical Protocol for ARP using GBR technique (a) The incisor in position 21 prior to extraction. (b) Atraumatic tooth extraction following incision of the gingival tissue. (c) De‐epithelialization of the gingival tissue collar and localised flap raised. (d) Socket filled with a xenograft bone substitute. (e) The collagen membrane was sutured in place to seal the socket aperture. (f) Graphical representation of ARP using GBR

FIGURE 2

Photographs demonstrating Surgical Protocol for ARP using SS technique (a) The incisor in position 11 prior to extraction. (b) Atraumatic tooth extraction with de‐epithelialization of the gingival tissue collar. (c) Socket filled with a xenograft bone substitute. (d) A collagen matrix placed over the xenograft bone substitute (e) The collagen matrix was sutured in place to seal the socket aperture. (f) Graphical representation of ARP using SS

FIGURE 3

Control patient demonstrating unassisted socket healing protocol. (a) and (b) Pictures of the incisor in position 21 prior to extraction. (c) Socket left to form primary clot, prior to application of sterile pack

FIGURE 4

Manufacture of radiographic Measurement stent at extraction site. (a) The incisor in position 11 prior to extraction. (b) 11 sectioned from the cast and buccal aspect trimmed to gingival margin position (c) Palatal aspect trimmed to gingival margin contour. (d) Extraction socket immediately following tooth removal. (e) Radiographic reference stent constructed to marked gingival contour. (f) Gingival margin positional change, immediately following tooth removal

FIGURE 5

CBCT radiographic measurement of the Mid BARH and PARH. (a) Buccal alveolar ridge height (BARH): The distance from the buccal alveolar bone crest to the base of the reference measurement stent. (b) Palatal alveolar crest ridge height (PARH): The distance from the palatal alveolar bone crest to the base of the reference measurement stent

FIGURE 6

CBCT radiographic measurement of the alveolar ridge width. (a) Coronal alveolar ridge width (CARW): The external width of the alveolar ridge at a distance 5mm from the radiographic stent. (b) Apical alveolar ridge width (AARW): The external width of the alveolar ridge at a distance of 10 mm from the index

FIGURE 7

CBCT Images demonstrating the 5 and 10 mm buccal socket measurement positions (a) and the grey scale histogram (b) produced by the Profile Measurement Tool, which was used to assist in the measurement of the buccal socket wall thickness

FIGURE 8

Superimposed CBCT Images demonstrating Alveolar bone change following 4‐months healing. (a) primary CBCT image taken after tooth extraction. (b) Secondary CBCT image taken at 4‐month healing. (c) Merged primary and secondary CBCT images, visualised using different colour masks. (*) orange colour represents original bone profile. (^) purple overlay outlines the residual morphology of the alveolar ridge when the secondary CBCT image was taken (4‐months)

FIGURE 9

Measurement of socket and alveolar process cross‐sectional area (mm².). (a) Primary socket (blue) and alveolar process area (green). (b) Primary alveolar process outline (green) and secondary healed outline (yellow). (c) Primary socket outline (blue), secondary healed outline (red)

FIGURE 10

Pictures of surgical osteotomy site, where additional GBR was required at implant placement to cover exposed implant threads (dehiscence)

FIGURE 11

VAS used for pain assessment with recording scale detailed below

FIGURE 12

Pictures of socket healing at 2‐weeks demonstrating local Complications. (a) Colour change with GBR group. (b) Dehiscence of the membrane with SS. (c) Dehiscence of the membrane with GBR. (d) Tissue recession with Control. (e) Sequestration of graft with SS. (f) Loss of the membrane with SS