Techniques for Socket Preservation Graft and Maintenance of Keratinized Gingiva

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Dental implant replacement of missing teeth requires both adequate hard and soft tissue for biologically compatible aesthetic and functional results, as well as longevity. Today we'll be discussing current techniques in extraction site socket preservation while optimizing the critically important soft tissue. Our guest is Dr. Ryan Kazemi, a board-certified oral and maxillofacial surgeon. He is the founder and CEO of Kazeme Oral Surgery and Dental Implants and maintains a full-time oral and maxillofacial surgery practice in Bethesda, Maryland. He is also the founder and director of Facial Art Dental Forum, a dental educational platform. Dr. Kazemi, it's a pleasure to have you on Dental Talk. Thank you very much. Appreciate it. Thanks for having me. Yeah, so this is a pretty... Relevant topic to our audience, implants are on the rise. GPs, in fact, doing many implants. So this information is very good. And we also are always concerned about the socket when we're doing an implant. That's very important for integration and the success, the long-term success of the final implant prosthesis. So why is socket preservation important in your mind and what techniques have commonly been used? Yeah, thank you. I think with the advances in teeth replacement treatment options, specifically implants, or even with conventional restorations that we used to use, the sacral preservation augmentation has never been more important and critical in our thinking process. Well, we all know that following tooth extraction and tooth loss, the bone and soft tissue undergoes a significant amount of atrophy and remodeling. And that particularly is seen more in the upper anterior when we have very thin bone, but it can pretty much happen in any site. And the effects of that is obviously with less bone for implant placement, which really impacts the aesthetics, the function, the hygiene requirements. and just the overall outcome of our cases. So at any given opportunity, if we can preserve and augment the socket, we will certainly have a much better outcome at the end of the treatment. So what are the indications for extraction site preservation grafts? Because we don't use them on every case. So in your mind, what's the determining factor for saying, yeah, in this case, we need to use a grafting material? Yeah, there are primarily three main indications that I look for. First of all, in the upper anterior and smile zone, in the aesthetic zone, we know that the bone is very thin and very often, even if the buccal plate is intact, following tooth extraction, the bone will resolve and we end up with deficiencies. So in the upper anterior area, as well as the lower anterior, a ridge preservation graft is often required. The other indication is if you have a tooth that has a lesion, a bone loss, whether it's the periodontal defect or lesion of endodontic origin or anything that has compromised one of the walls of the socket. And in that case, the tooth is removed and debrided and a socket augmentation graft should be done at that point. The third indication is a patient who we perform an extraction. And the bone is adequate. There is no defect. However, the patient, for whatever reason, may decide to have an implant placement much later. We know that the socket will go through some atrophy during that first few months. And eventually, at about 9 to 12 months, it becomes stable. So in patients who may decide to have an implant therapy for much later. we can do a socket preservation so we can minimize those remodeling changes. So what are some of the challenges that we should be aware of when it comes to conventional site preservation graphs? So the conventional site graph, what we have been using for years, the concept is placement of some type of particulate bone graft material which may be the autogenous it could be an allogenic bone it could be a xenogenic bone or an alloplast one of the bone particulate materials that's placed in the socket and then it is followed with either a GBR membrane which contains and protects the graft in place or some type of a collagen material to essentially keep it in place and that's kind of what we refer to as a conventional soccer graft using the guided bone regeneration principles which certainly has been quite effective it's a workhorse of our bone grafting techniques and certainly has proven to be quite effective and dependable over the years and well demonstrated in the literature and in our evidence-based studies The challenges that we face with conventional site preservation graft, I think kind of falls into two major challenges. Number one, following an extraction, we're going to have essentially an open wound. So once we do the bone graft placement and we cover it with, let's say, the GBR membrane, there is always possibility that that membrane is going to be exposed. And it may certainly kind of create situations where the membrane may be lost or mobilized out of the socket. And of course, we know that if the membrane is lost or even if it remains exposed, there is less vascularity to the top of the ridge. And that can compromise the amount and the quality of the bone. that we'll have after the healing process. So the first challenge is exposed membrane or potential loss of it during the healing phase. The second challenge is if we try to advance the gingival flap to try to close over the socket, which certainly will help to preserve and keep the membrane in place, but now we have changed the topography of the soft tissue. In essence, we have moved the mucogingival junction and the attached gingiva more toward the ridge or the crestal part. And that can have an implication later on, not only from an aesthetic standpoint in the upper anterior region, but also from standpoint of losing zone of creatinized gingiva, which we like to have, whether it's teeth or implants, is an important component of it. of the soft tissue topography there. So those are really the major two challenges in GBR techniques when it comes to suffix preservation. Right. Now, is there any solution to some of those challenges or anything that you do clinically that would simplify this process and improve predictable clinical outcomes? The critical factor in success of site graft and GBR techniques is keeping the bone in place and also keeping the membrane from dislodging and keeping it in. mobilized so how do we do that certainly by choosing a larger membrane where we can essentially tuck it into the soft tissue flap lingual or the palatal aspect and also the buccal aspect and using some retention sutures to try to keep it in place and minimize mobility also the size of the extraction socket can make an impact sometimes if you have a very thick tissue biotype in a smaller tooth such as a premolar or a central incisor or a canine it's easier to approximate the tissue and have a smaller area of secondary intention healing and that can work more in our favor but if you have a very wide area such as let's say a molar or even some situations where you have soft tissue deficiency now it becomes a larger area for the soft tissue to grow into and more challenges in secondary intention and of course the vascularity. So in those cases, we may have to advance the flap and actually provide more soft tissue coverage over the ridge. So these are some of the techniques, but it's really case dependent, it's site dependent, so we have to make some decisions. We have to make some good decisions based on anatomy, based on what type of tooth we're working on. based on the soft tissue biotype and the degree of defect. So there is no one shoe fits all kind of an approach. We have to respect the biology and anatomy of the area to make these decisions. Yeah, very well said, very well said. Tell us about this particular... grafting material foundation from jay marita i want to hear a little bit about that because i know you use this material called foundation what are its indications and how does it help with the whole process of preserving the extraction side socket yeah so you know it's interesting that in the in the history of bone grafting and tissue regeneration we're always looking for how to improve uh the biology of the bone graft as well as its application it's a user friendly and manipulation and handling so when we kind of look at an ideal situation or ideal bone graft or material how can it give us the best outcome from a preservation and augmentation standpoint but also make it easy to work with easy to place easy to pack and sort of contain into position uh so so those are all kind of variations of the factors that are important in our selection process ultimately the goal is to develop the implant site to develop the ridge so we can end up with an aesthetic functional and a kind of what i call a biologically compatible implant restoration system so in our search continually for how we can do this better and easier, and perhaps even less costly for the patient. It's interesting that we have this material called foundation, which is basically a telocollagen -based material. It is specifically, just to point out, it is not a bone substitute, as we routinely call a particulate bone graft, but rather it's a bone-stimulating collagen material that can be used and is quite helpful in following teeth extractions for a pre-implant site development. It's also helpful in let's say third molar extractions behind the second molars and the idea is that how it can stimulate the bone for better quality and quantity of bone and that's all we're looking for. The properties of this very interesting material is that it has a stimulating effect on the infiltration of the cells into the defect. And there's been some studies that showed that even with as early as eight weeks, there seems to be a generation of formed woven bone with good osteoblasts and ongoing bone formation even at that period. This material certainly is not an answer to all defects, but I think it has certain indications. For example, I think the main indication is to stimulate the bone regeneration and stimulate the soft tissue growth for an earlier implant placement and also to minimize. that shrinkage, that remodeling that we see quite often after extractions. Is this material used in conjunction with traditional or conventional site preservation grafting technique that you described earlier with bone material actually being placed in or can this be used on its own? Most of the studies or papers that have been written on this have been its utilization solely by itself. Essentially, the material comes in a couple of sizes, in a bullet-shaped format where it just kind of fits into the socket, rather easy to pack and form into place with just the retaining suture. However, I have used it both by itself for socket preservation and simulation type of an effect. but also I've used it in conjunction with defects where I've had bone defect, bone loss. So in those cases, I have done a conventional particulate bone graft, even with the GBR membrane, to help stimulate and grow the bone where it's necessary, and adding the foundation material more on the ridge aspect to help contain it. And because of the fact that I don't have to advance the soft tissue to try to close over it, that soft tissue essentially regenerates through secondary intention healing, restoring the attached gingiva without changing the topography of the ridge. So it's been a kind of an interesting observation that we can accomplish both bone augmentation and keeping the topography of the ridge. specifically with the soft tissue which is super important using this combination technique if you're doing extractions in anticipation of a denture would you use this material to maintain the ridge after the extractions absolutely pretty much it can be used in any extraction site defect because it provides the ability to preserve that space and hold the tissue from collapsing in so in that case it has maybe two benefits first of all it has a bone stimulation property for the socket to heal faster but at the same time it's kind of a space maintainer so the soft tissue will not collapse and maintain its shape better so it can be used for pre-implant preparation as we talked about third molar sockets certainly can be used let's say that we are using a conventional bridge in any area and we want to develop a pontic site so following extraction it can be used as a very easy technique to preserve the ridge where the pontic is going to be and that will have certainly favorable aesthetic and hygiene outcomes as well as certainly for denture just to preserve and maintain the tissue as much as possible. I think we've learned a lot about techniques for socket preservation. If you want more information on this material that Dr. Kazemi referred to, it's called Foundation. You can look it up on Jay Morita's website. Thank you very much, Dr. Kazemi, and we appreciate your input and hope to have you on another podcast in the future. I appreciate the invitation. Thank you so much. Appreciate it.