SYSTEMATIC REVIEW
Clinical and histologic outcomes of socket grafting after flapless tooth extraction: A systematic review of randomized controlled clinical trials Shantanu Jambhekar, BDS, MDS,a Florian Kernen, Dr med Dent,b and Avinash S. Bidra, BDS, MSc
ABSTRACT Statement of problem. Several biomaterials and techniques have been reported for socket grafting and alveolar ridge preservation. However, the evidence for clinical and histologic outcomes for socket grafting with different types of materials in flapless extraction is not clear. Purpose. The purpose of this systematic review was to analyze the outcomes of a socket grafting procedure performed with flapless extraction of teeth in order to determine which graft material results in the least loss of socket dimensions, the maximum amount of vital bone, the least remnant graft material, and the least amount of connective tissue after a minimum of 12 weeks of healing. Secondary outcomes, including the predictability of regenerating deficient buccal bone, necessity of barrier membranes, and coverage with autogenous soft tissue graft, were also evaluated. Material and methods. An electronic search for articles in the English-language literature was performed independently by multiple investigators using a systematic search process with the PubMed search engine. After applying predetermined inclusion and exclusion criteria, the final list of randomized controlled clinical trials (RCTs) for flapless extraction and socket grafting was analyzed to derive results for the various objectives of the study. Results. The initial electronic search resulted in 2898 titles. The systematic application of inclusion and exclusion criteria resulted in 32 RCTs studying 1354 sockets, which addressed the clinical and histologic outcomes of flapless extraction with socket grafting and provided dimensional and histologic information at or beyond the 12-week reentry period. From these RCTs, the mean loss of buccolingual width at the ridge crest was lowest for xenografts (1.3 mm), followed by allografts (1.63 mm), alloplasts (2.13 mm), and sockets without any socket grafting (2.79 mm). Only 3 studies reported on loss of width at 3 mm below the ridge crest. The mean loss of buccal wall height from the ridge crest was lowest for xenografts (0.57 mm) and allografts (0.58 mm), followed by alloplasts (0.77 mm) and sockets without any grafting (1.74 mm). The mean histologic outcomes at or beyond the 12-week reentry period revealed the highest vital bone content for sockets grafted with alloplasts (45.53%), followed by sockets with no graft material (41.07%), xenografts (35.72%), and allografts (29.93%). The amount of remnant graft material was highest for sockets grafted with allografts (21.75%), followed by xenografts (19.3%) and alloplasts (13.67%). The highest connective tissue content at the time of reentry was seen for sockets with no grafting (52.53%), followed by allografts (51.03%), xenografts (44.42%), and alloplast (38.39%). Data for new and emerging biomaterials such as cell therapy and tissue regenerative materials were not amenable to calculations because of biomaterial heterogeneity and small sample sizes. Conclusions. After flapless extraction of teeth, and using a minimum healing period of 12 weeks as a temporal measure, xenografts and allografts resulted in the least loss of socket dimensions compared to alloplasts or sockets with no grafting. Histologic outcomes after a minimum of 12 weeks of healing showed that sockets grafted with alloplasts had the maximum amount of vital bone and the least amount of remnant graft material and remnant connective tissue. There is a limited but emerging body of evidence for the predictable regeneration of deficient buccal bone with socket grafting materials, need for barrier membranes, use of tissue engineering, and use of autogenous soft tissue grafts from the palate to cover the socket. (J Prosthet Dent 2015;-:---)
a
Assistant Professor, Terna Dental College Nerul, Mumbai, India; Former ITI Scholar, Department of Reconstructive Sciences University of Connecticut Health Center, Farmington, Conn. b Former prosthodontics fellow, Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, Conn. c Program Director, Department of Reconstructive Sciences, Post-Graduate Prosthodontics, University of Connecticut Health Center, Farmington, Conn.
THE JOURNAL OF PROSTHETIC DENTISTRY
1
2
Volume
Clinical Implications After a flapless tooth extraction, socket grafting is recommended as a preprosthetic procedure to minimize the loss of socket width and buccal wall height. Xenografts or allografts are a good choice for minimizing the loss of buccolingual width, while alloplasts attain the maximum amount of vital bone after 12 weeks. A minimum healing period of over 12 weeks is recommended for favorable biologic outcomes before implant placement. The alveolar process is a tooth-dependent tissue, which develops along with the eruption of the teeth. The extraction of a tooth initiates a series of reparative processes involving both hard tissue (alveolar bone) and soft tissues (periodontal ligament, gingiva).1-4 The chronological sequence of biologic events occurring during the healing of an extraction socket result in alveolar ridge resorption.1-8 This phenomenon appears to be progressive and irreversible, resulting in myriad prosthodontic, esthetic, and functional challenges during the replacement of missing teeth. Several human studies evaluating the healing of extraction socket have confirmed that the alveolar process atrophies after the loss of single or multiple teeth.9-53 Smukler et al54 reported that resorption is more pronounced in the mandible than in the maxilla and that the buccal side loses more volume than the lingual. The greatest amount of bone loss occurs in the horizontal dimension, mainly on the facial aspect of the ridge. Loss of vertical ridge height has been described as most pronounced on the buccal aspect.9,55-58 Socket grafting or ridge preservation involves grafting the extraction socket with biomaterial alone or in combination with barrier membrane and/or an advanced or rotated pedicle flap/connective tissue/free gingival graft.59 The popular term “socket preservation” is a misnomer, as it may imply preservation or maintenance of the socket in its original or existing state, which is obviously undesirable. A number of biomaterials and techniques for socket grafting have been reported and can be grouped into 4 categories (Table 1).59 In recent years, 13 systematic reviews have addressed the healing of extraction sockets and the dimensional changes (height and width) of the hard and soft tissues of the alveolar ridge.60-72 A general consensus among the results of these 13 systematic reviews is that although socket grafting did not completely prevent bone resorption, it appeared to be effective in preserving the alveolar ridge volume compared with extraction alone. Nevertheless, many deficiencies remain from previous 13 systematic reviews. No systematic reviews have attempted to compare the clinical and histologic outcomes between various socket grafting materials or answer questions relating to temporal measures and THE JOURNAL OF PROSTHETIC DENTISTRY
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Issue
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healing. Additionally, previous systematic reviews have all grouped socket grafting outcomes after flapless and flap surgical approaches of teeth extractions.60-72 Flapless approach for teeth extractions is known to be a simple, atraumatic, and conservative method. Various authors have reported improved clinical outcomes with the flapless approach for teeth extractions with reduced healing times, discomfort, and inflammation.23,46,47 Flapless extraction of teeth entails nondetachment of the periosteum and therefore preserves blood supply to the underlying buccal bone and has been accounted for the reduced loss of alveolar bone compared to a flapless extraction.23,46,47,73-77 In a recent randomized clinical trial, Barone et al47 showed that the flapless technique could preserve the horizontal hard tissue dimension and increase the keratinized gingiva more successfully than the flapped technique for tooth extraction. The primary purpose of this systematic review was to analyze the clinical outcomes of socket grafting procedures performed with the flapless extraction of teeth to find out which graft material results in the least loss of socket dimensions, the maximum amount of vital bone, the least remnant graft material, and the least connective tissue after a minimum of 12 weeks of healing. Secondary outcomes, including the predictability of regenerating deficient buccal bone, the need for barrier membranes, and coverage with autogenous soft tissue grafts, were also evaluated. MATERIAL AND METHODS An independent electronic search of the Englishlanguage literature was performed by multiple investigators using the PubMed search engine and the Cochrane Library database. The specific terms that were used for the electronic search were tooth extraction and socket grafting OR tooth extraction and socket preservation OR tooth extraction and ridge preservation or tooth extraction and alveolar ridge preservation OR tooth extraction and socket seal OR tooth extraction and allograft OR tooth extraction and bio-oss OR tooth extraction and fdba OR tooth extraction and bovine bone OR tooth extraction and collagen OR tooth extraction and dfdba OR tooth extraction and biomaterial OR tooth extraction and ridge augmentation OR tooth extraction and platelet OR tooth extraction and plasma OR tooth extraction and calcium sulfate OR tooth extraction and calcium phosphate OR tooth extraction and site development OR tooth extraction and alloplast OR tooth extraction and porcine bone OR tooth extraction and ridge healing OR tooth extraction and bone morphogenic protein OR tooth extraction and buccal bone OR tooth extraction and hydroxyapatite OR tooth extraction and bioceramic material OR tooth extraction and post extraction OR tooth extraction and membrane OR tooth extraction and autogenous bone OR tooth extraction and Jambhekar et al
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2015
3
Table 1. Overview of biomaterials used for socket grafting59 Biomaterial Type
Definition*
Autogenous bone graft
Bone graft taken from an intraoral or extraoral site and placed in same individual. Origin of graft will determine whether it is cortical, corticocancellous, or cancellous in nature.
Allogenic bone graft (allograft)
Graft between genetically dissimilar members of same species. Iliac cancellous bone and marrow, freeze-dried bone allograft (FDBA), and demineralized freeze-dried bone allograft (DFDBA) are available commercially from tissue banks.
Xenogenic bone graft (xenograft)
Graft obtained from a donor of another species; also termed heterograft.
Alloplastic bone graft (alloplast)
Graft material such as hydroxyapatite (HA), tricalcium phosphate (TCP), polymethylmethacrylate (PMMA), and hydroxyethyl methacrylate (HEMA) polymer, or bioactive glass that is derived either synthetically or from a foreign, inert source.
Other materials
Platelet-rich plasma (PRP), platelet-rich fibrin (PRF), gone morphogenetic protein (BMP), Emdogain (EMD), cell therapy.
*Glossary of Oral and Maxillofacial Implants.
bone regeneration OR tooth extraction and bone substitute OR tooth extraction and connective tissue graft OR tooth extraction and flap OR tooth extraction and flapless OR tooth extraction and ridge change OR tooth extraction and socket healing OR tooth extraction and synthetic graft OR tooth extraction and xenograft OR tooth extraction and beta tcp. The Patient-Intervention-Control-Outcome (PICO) question for this systematic review was, in patients with flapless extraction of teeth, does socket grafting with a specific type of material (xenograft, allograft, alloplast, or other materials) compared to sockets with no graft material, provide superior clinical and histologic outcomes after a 12-week healing period? The publication dates searched were of studies published from January 1, 1990, to November 12, 2013. The only search limits applied to the electronic search was the English language and the publication date range. The predetermined inclusion and exclusion criteria are reported in Table 2. The electronic search process was systematically conducted in 3 stages. In stage 1, the investigators independently screened all relevant titles of the electronic search, and any disagreement was resolved by discussion. In situations where the application of the exclusion criteria was not clear, the controversial article was included for consideration in the abstract stage. In stage 2, the investigators independently analyzed the abstracts of all selected titles, and disagreements were resolved by discussion. In situations of uncertainty, the abstract was included for the subsequent full-text stage. After the application of the exclusion criteria, the definitive list of articles was screened at stage 3 by the investigators to extract qualitative and quantitative data. A supplemental search was conducted on the basis of the references from the definitive list of fulltext articles from stage 3 and additional articles published beyond the terminal search date (November 12, 2013, to July 1, 2014). Data from all included randomized controlled trials (RCTs) were then tabulated, analyzed, and compared for various graft materials. RESULTS The initial electronic search using the specific search terms from the PubMed search engine resulted in a total Jambhekar et al
Table 2. Predetermined eligibility criteria for inclusion and exclusion Inclusion Criteria
Any English-language articles published in peer-reviewed journal.
Any RCT involving any of search terms.
Exclusion Criteria
Articles that did not pertain to items described in inclusion criteria.
RCTs that did not describe data on flapless extraction of teeth.
RCTs that did not describe data at or beyond 12-week healing period after flapless extraction.
Articles that did not pertain to objectives of systematic review.
Nonrandomized clinical studies, review articles, or technique articles without associated clinical study and data.
Articles that did not report on follow-up period before reentry into socket.
Articles that reported on socket grafting for purposes other than site development for implant placement.
Patients or data repeated in other included articles.
Article description that would not allow extraction of quantitative data related to study objectives.
RCT, randomized controlled trial.
of 2898 titles, out of which 181 abstracts were applicable to the study. Further scrutiny resulted in the elimination of 162 full-text articles. A supplementary search for articles published after the terminal search date (November 12, 2013, to July 1, 2014) was done; articles were directly subjected to full-text analysis and predetermined exclusion criteria were applied. This eventually resulted in a total of 32 RCTs that reported the clinical and histologic outcomes at or beyond the 12-week reentry period. These 32 RCTs were included for qualitative and quantitative data extraction and analysis, and data were grouped into various types of graft materials and techniques, all of which were intended to answer the PICO question and the study objectives (Tables 3, 4, Fig. 1). Sockets without any graft material A total of 22 of 32 RCTs reported on the flapless extraction of teeth with no graft material being placed into the socket. A total of 397 extraction sockets in 17 studies10,12-14,16-24,26-29 reported histologic outcomes and/ or changes in the buccolingual dimension and buccal wall height at reentry at or beyond 12 weeks. The mean loss of the buccolingual width at the crest level was 2.79 mm (9 studies),12,16,17,18,19,21,26,27,29 and the mean loss was 1.74 mm (10 studies)10,12,13,17,18,21,22,24,26,27 in the buccal wall height from the ridge crest. Similarly, for a 12- week THE JOURNAL OF PROSTHETIC DENTISTRY
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Table 3. Qualitative analysis of 32 randomized controlled clinical trials Study
Year
Nahles
10
Specified Reason for Tooth Extraction
Age (y), Mean (Range)
Sex Distribution
Method of Measurement for Dimensional Changes
Extraction Site
2013
NR
54.5 (30-73)
18 M, 15 F
Various teeth in both jaws
NR
Aimetti12
2009
Root or crown fractures, nonrestorable caries, residual roots
51.2 (36-68)
18 M, 22 F
Anterior maxilla
Direct measurements using a template and Williams periodontal probe
Crespi13
2009
NR
51.3 (28-72)
8 M, 7 F
1 on each side of jaw, in molar or premolar regions (n=30), and 1 additional random tooth, used for control (n=15)
Radiographic bone measurement
Heberer14
2011
NR
49.9 (36-67)
15 M, 10 F
Maxillary and mandibular molars
NR
2010
NR
NR (15-87)
63 M, 62 F
NR
Cast-based measurements
2012
Tooth fracture, endodontic reasons, severely decayed, nonrestorable teeth, periodontal reasons
40.5 (20-63)
20 M, 39 F
Premolars and molars
Direct measurements using periodontal probe
2012
Tooth fracture, periodontal involvement, endodontic treatment failures, advanced caries lesions
47.2 (24-71)
24 M, 17 F
Premolars and molars
Cast-based measurements using UNC probe
2011
NR
53.7 (32-70)
8 M, 7 F
3 teeth (1 molar or premolar from each side and 1 random as control)
NR
2011
NR
53.7 (32-70)
6 M, 9 F
2013
Root fractures, advanced caries lesions, endodontic failures with intact buccal plate
46.2 (24-72)
13 F
2013
NR
NR (28-58)
2010
NR
2013
Oghli
16
Barone17
Cardaropoli
18
Crespi19
Crespi20
Premolar and molar
NR
Anterior maxilla up to second premolar
Casts scanned and superimposed
6 M, 9 F
Symmetrical maxillary or mandibular contralateral premolars
Direct measurements via customized acrylic template and k file
47.5 (28-70)
7 M, 6 F
Anterior teeth
Direct measurements using periodontal probe
Caries, periodontitis, endodontic complications (eg, root fracture), orthodontic, prosthetic
NR (48-65)
18 M 23 F
1 maxillary or mandibular asymptomatic anterior tooth or premolar
Direct measurements using periodontal probe
2013
NR
NR (25-54)
NR
Maxillary and mandibular anteriors and premolars
NR
Schneider29
2014
Caries, endodontic complications, root fracture, periodontitis, orthodontic, prosthetic
NR
NR
Maxillary and mandibular incisors, canines, premolars
Cast digitized and assessed for volumetric changes
Brownfield32
2012
Compromised or nonrestorable nonmolar teeth with adjacent teeth present
NR (25-69)
5 M, 12 F
Nonmolar teeth
Direct measurement, radiographic guide, and cone beam computerized tomography
Toloue33
2012
NR
NR (18-75 M; 18-50 F)
11 M, 10 F
Single-rooted nonmolar tooth
Direct measurements using UNC-15 probe and caliper
22
Thalmair
Festa
24
Pelegrine Jung
26
27
Lindhe
Fotek
28
34
2009
NR
NR (29-77)
5 M, 13 F
Central incisor, canine, premolar
Direct measurements using acrylic template, UNC probe, caliper
35
2012
NR
56.7 (20-78)
13 M, 20 F
Single-rooted nonmolar tooth
Direct measurements using UNC-15 probe and caliper
Eskow36
2013
Various reasons, but all teeth had
Clinical and histologic outcomes of socket grafting after flapless tooth extraction: A systematic review of randomized controlled clinical trials Shantanu Jambhekar, BDS, MDS,a Florian Kernen, Dr med Dent,b and Avinash S. Bidra, BDS, MSc
ABSTRACT Statement of problem. Several biomaterials and techniques have been reported for socket grafting and alveolar ridge preservation. However, the evidence for clinical and histologic outcomes for socket grafting with different types of materials in flapless extraction is not clear. Purpose. The purpose of this systematic review was to analyze the outcomes of a socket grafting procedure performed with flapless extraction of teeth in order to determine which graft material results in the least loss of socket dimensions, the maximum amount of vital bone, the least remnant graft material, and the least amount of connective tissue after a minimum of 12 weeks of healing. Secondary outcomes, including the predictability of regenerating deficient buccal bone, necessity of barrier membranes, and coverage with autogenous soft tissue graft, were also evaluated. Material and methods. An electronic search for articles in the English-language literature was performed independently by multiple investigators using a systematic search process with the PubMed search engine. After applying predetermined inclusion and exclusion criteria, the final list of randomized controlled clinical trials (RCTs) for flapless extraction and socket grafting was analyzed to derive results for the various objectives of the study. Results. The initial electronic search resulted in 2898 titles. The systematic application of inclusion and exclusion criteria resulted in 32 RCTs studying 1354 sockets, which addressed the clinical and histologic outcomes of flapless extraction with socket grafting and provided dimensional and histologic information at or beyond the 12-week reentry period. From these RCTs, the mean loss of buccolingual width at the ridge crest was lowest for xenografts (1.3 mm), followed by allografts (1.63 mm), alloplasts (2.13 mm), and sockets without any socket grafting (2.79 mm). Only 3 studies reported on loss of width at 3 mm below the ridge crest. The mean loss of buccal wall height from the ridge crest was lowest for xenografts (0.57 mm) and allografts (0.58 mm), followed by alloplasts (0.77 mm) and sockets without any grafting (1.74 mm). The mean histologic outcomes at or beyond the 12-week reentry period revealed the highest vital bone content for sockets grafted with alloplasts (45.53%), followed by sockets with no graft material (41.07%), xenografts (35.72%), and allografts (29.93%). The amount of remnant graft material was highest for sockets grafted with allografts (21.75%), followed by xenografts (19.3%) and alloplasts (13.67%). The highest connective tissue content at the time of reentry was seen for sockets with no grafting (52.53%), followed by allografts (51.03%), xenografts (44.42%), and alloplast (38.39%). Data for new and emerging biomaterials such as cell therapy and tissue regenerative materials were not amenable to calculations because of biomaterial heterogeneity and small sample sizes. Conclusions. After flapless extraction of teeth, and using a minimum healing period of 12 weeks as a temporal measure, xenografts and allografts resulted in the least loss of socket dimensions compared to alloplasts or sockets with no grafting. Histologic outcomes after a minimum of 12 weeks of healing showed that sockets grafted with alloplasts had the maximum amount of vital bone and the least amount of remnant graft material and remnant connective tissue. There is a limited but emerging body of evidence for the predictable regeneration of deficient buccal bone with socket grafting materials, need for barrier membranes, use of tissue engineering, and use of autogenous soft tissue grafts from the palate to cover the socket. (J Prosthet Dent 2015;-:---)
a
Assistant Professor, Terna Dental College Nerul, Mumbai, India; Former ITI Scholar, Department of Reconstructive Sciences University of Connecticut Health Center, Farmington, Conn. b Former prosthodontics fellow, Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, Conn. c Program Director, Department of Reconstructive Sciences, Post-Graduate Prosthodontics, University of Connecticut Health Center, Farmington, Conn.
THE JOURNAL OF PROSTHETIC DENTISTRY
1
2
Volume
Clinical Implications After a flapless tooth extraction, socket grafting is recommended as a preprosthetic procedure to minimize the loss of socket width and buccal wall height. Xenografts or allografts are a good choice for minimizing the loss of buccolingual width, while alloplasts attain the maximum amount of vital bone after 12 weeks. A minimum healing period of over 12 weeks is recommended for favorable biologic outcomes before implant placement. The alveolar process is a tooth-dependent tissue, which develops along with the eruption of the teeth. The extraction of a tooth initiates a series of reparative processes involving both hard tissue (alveolar bone) and soft tissues (periodontal ligament, gingiva).1-4 The chronological sequence of biologic events occurring during the healing of an extraction socket result in alveolar ridge resorption.1-8 This phenomenon appears to be progressive and irreversible, resulting in myriad prosthodontic, esthetic, and functional challenges during the replacement of missing teeth. Several human studies evaluating the healing of extraction socket have confirmed that the alveolar process atrophies after the loss of single or multiple teeth.9-53 Smukler et al54 reported that resorption is more pronounced in the mandible than in the maxilla and that the buccal side loses more volume than the lingual. The greatest amount of bone loss occurs in the horizontal dimension, mainly on the facial aspect of the ridge. Loss of vertical ridge height has been described as most pronounced on the buccal aspect.9,55-58 Socket grafting or ridge preservation involves grafting the extraction socket with biomaterial alone or in combination with barrier membrane and/or an advanced or rotated pedicle flap/connective tissue/free gingival graft.59 The popular term “socket preservation” is a misnomer, as it may imply preservation or maintenance of the socket in its original or existing state, which is obviously undesirable. A number of biomaterials and techniques for socket grafting have been reported and can be grouped into 4 categories (Table 1).59 In recent years, 13 systematic reviews have addressed the healing of extraction sockets and the dimensional changes (height and width) of the hard and soft tissues of the alveolar ridge.60-72 A general consensus among the results of these 13 systematic reviews is that although socket grafting did not completely prevent bone resorption, it appeared to be effective in preserving the alveolar ridge volume compared with extraction alone. Nevertheless, many deficiencies remain from previous 13 systematic reviews. No systematic reviews have attempted to compare the clinical and histologic outcomes between various socket grafting materials or answer questions relating to temporal measures and THE JOURNAL OF PROSTHETIC DENTISTRY
-
Issue
-
healing. Additionally, previous systematic reviews have all grouped socket grafting outcomes after flapless and flap surgical approaches of teeth extractions.60-72 Flapless approach for teeth extractions is known to be a simple, atraumatic, and conservative method. Various authors have reported improved clinical outcomes with the flapless approach for teeth extractions with reduced healing times, discomfort, and inflammation.23,46,47 Flapless extraction of teeth entails nondetachment of the periosteum and therefore preserves blood supply to the underlying buccal bone and has been accounted for the reduced loss of alveolar bone compared to a flapless extraction.23,46,47,73-77 In a recent randomized clinical trial, Barone et al47 showed that the flapless technique could preserve the horizontal hard tissue dimension and increase the keratinized gingiva more successfully than the flapped technique for tooth extraction. The primary purpose of this systematic review was to analyze the clinical outcomes of socket grafting procedures performed with the flapless extraction of teeth to find out which graft material results in the least loss of socket dimensions, the maximum amount of vital bone, the least remnant graft material, and the least connective tissue after a minimum of 12 weeks of healing. Secondary outcomes, including the predictability of regenerating deficient buccal bone, the need for barrier membranes, and coverage with autogenous soft tissue grafts, were also evaluated. MATERIAL AND METHODS An independent electronic search of the Englishlanguage literature was performed by multiple investigators using the PubMed search engine and the Cochrane Library database. The specific terms that were used for the electronic search were tooth extraction and socket grafting OR tooth extraction and socket preservation OR tooth extraction and ridge preservation or tooth extraction and alveolar ridge preservation OR tooth extraction and socket seal OR tooth extraction and allograft OR tooth extraction and bio-oss OR tooth extraction and fdba OR tooth extraction and bovine bone OR tooth extraction and collagen OR tooth extraction and dfdba OR tooth extraction and biomaterial OR tooth extraction and ridge augmentation OR tooth extraction and platelet OR tooth extraction and plasma OR tooth extraction and calcium sulfate OR tooth extraction and calcium phosphate OR tooth extraction and site development OR tooth extraction and alloplast OR tooth extraction and porcine bone OR tooth extraction and ridge healing OR tooth extraction and bone morphogenic protein OR tooth extraction and buccal bone OR tooth extraction and hydroxyapatite OR tooth extraction and bioceramic material OR tooth extraction and post extraction OR tooth extraction and membrane OR tooth extraction and autogenous bone OR tooth extraction and Jambhekar et al
-
2015
3
Table 1. Overview of biomaterials used for socket grafting59 Biomaterial Type
Definition*
Autogenous bone graft
Bone graft taken from an intraoral or extraoral site and placed in same individual. Origin of graft will determine whether it is cortical, corticocancellous, or cancellous in nature.
Allogenic bone graft (allograft)
Graft between genetically dissimilar members of same species. Iliac cancellous bone and marrow, freeze-dried bone allograft (FDBA), and demineralized freeze-dried bone allograft (DFDBA) are available commercially from tissue banks.
Xenogenic bone graft (xenograft)
Graft obtained from a donor of another species; also termed heterograft.
Alloplastic bone graft (alloplast)
Graft material such as hydroxyapatite (HA), tricalcium phosphate (TCP), polymethylmethacrylate (PMMA), and hydroxyethyl methacrylate (HEMA) polymer, or bioactive glass that is derived either synthetically or from a foreign, inert source.
Other materials
Platelet-rich plasma (PRP), platelet-rich fibrin (PRF), gone morphogenetic protein (BMP), Emdogain (EMD), cell therapy.
*Glossary of Oral and Maxillofacial Implants.
bone regeneration OR tooth extraction and bone substitute OR tooth extraction and connective tissue graft OR tooth extraction and flap OR tooth extraction and flapless OR tooth extraction and ridge change OR tooth extraction and socket healing OR tooth extraction and synthetic graft OR tooth extraction and xenograft OR tooth extraction and beta tcp. The Patient-Intervention-Control-Outcome (PICO) question for this systematic review was, in patients with flapless extraction of teeth, does socket grafting with a specific type of material (xenograft, allograft, alloplast, or other materials) compared to sockets with no graft material, provide superior clinical and histologic outcomes after a 12-week healing period? The publication dates searched were of studies published from January 1, 1990, to November 12, 2013. The only search limits applied to the electronic search was the English language and the publication date range. The predetermined inclusion and exclusion criteria are reported in Table 2. The electronic search process was systematically conducted in 3 stages. In stage 1, the investigators independently screened all relevant titles of the electronic search, and any disagreement was resolved by discussion. In situations where the application of the exclusion criteria was not clear, the controversial article was included for consideration in the abstract stage. In stage 2, the investigators independently analyzed the abstracts of all selected titles, and disagreements were resolved by discussion. In situations of uncertainty, the abstract was included for the subsequent full-text stage. After the application of the exclusion criteria, the definitive list of articles was screened at stage 3 by the investigators to extract qualitative and quantitative data. A supplemental search was conducted on the basis of the references from the definitive list of fulltext articles from stage 3 and additional articles published beyond the terminal search date (November 12, 2013, to July 1, 2014). Data from all included randomized controlled trials (RCTs) were then tabulated, analyzed, and compared for various graft materials. RESULTS The initial electronic search using the specific search terms from the PubMed search engine resulted in a total Jambhekar et al
Table 2. Predetermined eligibility criteria for inclusion and exclusion Inclusion Criteria
Any English-language articles published in peer-reviewed journal.
Any RCT involving any of search terms.
Exclusion Criteria
Articles that did not pertain to items described in inclusion criteria.
RCTs that did not describe data on flapless extraction of teeth.
RCTs that did not describe data at or beyond 12-week healing period after flapless extraction.
Articles that did not pertain to objectives of systematic review.
Nonrandomized clinical studies, review articles, or technique articles without associated clinical study and data.
Articles that did not report on follow-up period before reentry into socket.
Articles that reported on socket grafting for purposes other than site development for implant placement.
Patients or data repeated in other included articles.
Article description that would not allow extraction of quantitative data related to study objectives.
RCT, randomized controlled trial.
of 2898 titles, out of which 181 abstracts were applicable to the study. Further scrutiny resulted in the elimination of 162 full-text articles. A supplementary search for articles published after the terminal search date (November 12, 2013, to July 1, 2014) was done; articles were directly subjected to full-text analysis and predetermined exclusion criteria were applied. This eventually resulted in a total of 32 RCTs that reported the clinical and histologic outcomes at or beyond the 12-week reentry period. These 32 RCTs were included for qualitative and quantitative data extraction and analysis, and data were grouped into various types of graft materials and techniques, all of which were intended to answer the PICO question and the study objectives (Tables 3, 4, Fig. 1). Sockets without any graft material A total of 22 of 32 RCTs reported on the flapless extraction of teeth with no graft material being placed into the socket. A total of 397 extraction sockets in 17 studies10,12-14,16-24,26-29 reported histologic outcomes and/ or changes in the buccolingual dimension and buccal wall height at reentry at or beyond 12 weeks. The mean loss of the buccolingual width at the crest level was 2.79 mm (9 studies),12,16,17,18,19,21,26,27,29 and the mean loss was 1.74 mm (10 studies)10,12,13,17,18,21,22,24,26,27 in the buccal wall height from the ridge crest. Similarly, for a 12- week THE JOURNAL OF PROSTHETIC DENTISTRY
4
Volume
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Issue
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Table 3. Qualitative analysis of 32 randomized controlled clinical trials Study
Year
Nahles
10
Specified Reason for Tooth Extraction
Age (y), Mean (Range)
Sex Distribution
Method of Measurement for Dimensional Changes
Extraction Site
2013
NR
54.5 (30-73)
18 M, 15 F
Various teeth in both jaws
NR
Aimetti12
2009
Root or crown fractures, nonrestorable caries, residual roots
51.2 (36-68)
18 M, 22 F
Anterior maxilla
Direct measurements using a template and Williams periodontal probe
Crespi13
2009
NR
51.3 (28-72)
8 M, 7 F
1 on each side of jaw, in molar or premolar regions (n=30), and 1 additional random tooth, used for control (n=15)
Radiographic bone measurement
Heberer14
2011
NR
49.9 (36-67)
15 M, 10 F
Maxillary and mandibular molars
NR
2010
NR
NR (15-87)
63 M, 62 F
NR
Cast-based measurements
2012
Tooth fracture, endodontic reasons, severely decayed, nonrestorable teeth, periodontal reasons
40.5 (20-63)
20 M, 39 F
Premolars and molars
Direct measurements using periodontal probe
2012
Tooth fracture, periodontal involvement, endodontic treatment failures, advanced caries lesions
47.2 (24-71)
24 M, 17 F
Premolars and molars
Cast-based measurements using UNC probe
2011
NR
53.7 (32-70)
8 M, 7 F
3 teeth (1 molar or premolar from each side and 1 random as control)
NR
2011
NR
53.7 (32-70)
6 M, 9 F
2013
Root fractures, advanced caries lesions, endodontic failures with intact buccal plate
46.2 (24-72)
13 F
2013
NR
NR (28-58)
2010
NR
2013
Oghli
16
Barone17
Cardaropoli
18
Crespi19
Crespi20
Premolar and molar
NR
Anterior maxilla up to second premolar
Casts scanned and superimposed
6 M, 9 F
Symmetrical maxillary or mandibular contralateral premolars
Direct measurements via customized acrylic template and k file
47.5 (28-70)
7 M, 6 F
Anterior teeth
Direct measurements using periodontal probe
Caries, periodontitis, endodontic complications (eg, root fracture), orthodontic, prosthetic
NR (48-65)
18 M 23 F
1 maxillary or mandibular asymptomatic anterior tooth or premolar
Direct measurements using periodontal probe
2013
NR
NR (25-54)
NR
Maxillary and mandibular anteriors and premolars
NR
Schneider29
2014
Caries, endodontic complications, root fracture, periodontitis, orthodontic, prosthetic
NR
NR
Maxillary and mandibular incisors, canines, premolars
Cast digitized and assessed for volumetric changes
Brownfield32
2012
Compromised or nonrestorable nonmolar teeth with adjacent teeth present
NR (25-69)
5 M, 12 F
Nonmolar teeth
Direct measurement, radiographic guide, and cone beam computerized tomography
Toloue33
2012
NR
NR (18-75 M; 18-50 F)
11 M, 10 F
Single-rooted nonmolar tooth
Direct measurements using UNC-15 probe and caliper
22
Thalmair
Festa
24
Pelegrine Jung
26
27
Lindhe
Fotek
28
34
2009
NR
NR (29-77)
5 M, 13 F
Central incisor, canine, premolar
Direct measurements using acrylic template, UNC probe, caliper
35
2012
NR
56.7 (20-78)
13 M, 20 F
Single-rooted nonmolar tooth
Direct measurements using UNC-15 probe and caliper
Eskow36
2013
Various reasons, but all teeth had
