Socket preservation

Socket preservation

Socket preservation techniques depend on both the severity of the graft site and the host response.  If there is no bone destruction a membrane alone will often be suffice.  If there is any bone destruction then FDBA and membrane use is recommended.  Post surgical care requires CHX rinse twice daily for 2 weeks to 1 month and antibiotics for 7 days.  The dental implant is placed 3-4 months for cases with uneventful healing or 6 months for cases with advanced bone loss.  Some membranes like alloderm, PTFE, and guidor can be left exposed.

Socket preservation step by step

This varies significantly by doctor preference and material use. There are many ways to do this successfully.

  1. Thorough curettage of socket.
  2. Copious saline irrigation, CHX irrigation, saline irrigation
  3. Bone graft or graft of choice.
  4. Antibiotic regimen, pick your favorite regimen.
  5. Cover with some sort of membrane or PRF in some cases.
  6. Suture and post op instructions.

The invidual’s ability to heal have as much to do with success as just about anything except doctor’s skill and experience.

Dental code for socket preservation

Bone Graft dental Code for Socket Preservation in Extraction Socket

  • D7953, Bone Replacement Graft for Ridge Preservation
    • CDT descriptor: “Osseous autograft, allograft or non-osseous graft is placed in an extraction or implant removal site at the time of the extraction or removal to preserve ridge integrity (e.g., clinically indicated in preparation for implant reconstruction or where alveolar contour is critical to planned prosthetic reconstruction). Membrane, if used should be reported separately.”
    • This is for a graft to fill in the hole where the tooth or implant was just removed.
Image of socket preservation bone graft.
Socket preservation bone graft of #8 with collagen membrane.

Appeal to dental insurance for socket preservation

“Please reconsider socket preservation at the time of extraction.  Current position taken by the literature indicates that particulate bone graft material placed into the socket at the time of extraction reduces horizontal dimension of ridge resorption (Schropp 2003, Fickl 2008, van der Weijden 2009, Chen 2009).  On average non-grafted sites exhibit 30% loss of horizontal dimension while grafted sites exhibit only 13% loss of horizontal dimension (Iasella 2003). Failure to preserve the available bone through socket grafting at the time of extraction may compromise future ability to place implant in the area requiring further future grafting techniques when the implant is placed at a later date.”

“Socket preservation at time of extraction is becoming the standard of care, especially if future implant is planned.  This is because the blood supply and the natural soft-tissue anatomy at the edentulous site needs to be preserved to provide for a long term restorable solution (fixed, removable, etc…).  Ultimately, the avoidance of post-extraction bone resorption and the preservation of the natural soft-tissue anatomy at the endentulous site become the key elements to obtaining an optimal rehabilitation of the site, and can be avoided with a socket preservation procedure.  By not performing a socket preservation procedure, I would be compromising the long term oral health of my patient. If you cover implant this procedure should also be covered without question.  Please reconsider payment.  Thanks”

Alveolar ridge preservation or socket preservation research

Meta-analysis shows that it saves 1.86mm in the horizontal direction and sockets with damaged walls save 2.88mm. A barrier membrane increases the amount of bone that we save, you do not want to use alloplast grafting material, and prf has no hard tissue impact. Bassir JOMI 2018

Socket preservation classification

socket preservation classification grade I grade II grade III
Grade I on left, Grade II in middle, and Grade III on right

Chaar et all classification is the one above and they classify teeth based on buccal bone.  The importance of thick versus thin biotype is emphasized.

Elian classification

Elian et al classification is based on hard and soft tissue loss pre extraction.  The treatment recommendations, at that time anyway, are found below.

Type 1—Labial bone plate and associated soft tissues are completely intact.

Type 2—Soft tissue is present, but a dehiscence osseous defect exists that is indicative of the partial or complete absence of the labial bone plate.

Type 3—Midfacial recession defect is present, representing the loss of the labial bone plate and soft tissues.

Tarnow and Chu have a further sub-classification of the Type 2 category, which seems like a rather obvious breakdown by how much bone loss is present.

socket preservation classification soft hard tissue

Socket classifications and treatment protocol

Socket classifications and treatment protocol

Elian et al recommendations for their classification system may be outdated and it is only for cases that you are not doing an immediate implant.  The Type I sockets are simple bone grafting cases.  Type II sockets are easy to misdiagnose as Type I due to the difficulty to determine presence of the buccal plate.  Type II cases utilize the ice cream cone bone grafting technique.  The type III sockets require multiple steps and surgeries with SECTG.

Immediate Dentoalveolar Restoration

Immediate Dentoalveolar Restoration is the name José Carlos Martins da Rosa has given his grafting techique to do an immediate implant placement and immediate temporization. It consists of taking a block of bone from the tuberosity and fitting like a puzzle piece into the missing socket wall, then backfiling the space with more bone. It is similar to a flapless Khoury Block technique.