A case of socket preservation technique is presented with a review of Literature

1. PRESERVATION OF THE RIDGE
AND SEALING OF THE SOCKET
WITH A COMBINATION OF
EPITHELIALISED-SUBEPITHELIAL
CONNECTIVE TISSUE GRAFT.

2. INTRODUCTION
 An implant-supported rehabilitation continues to be a major challenge in patients with
inadequate residual ridge.
 Socket preservation and immediate implant placement are intended to preserve the hard
tissue volume and prevent pre implant bone loss following tooth extraction.
 Immediate implant placement is a technique-sensitive procedure which needs proper
planning from an experienced clinician and tooth to be replaced should have healthy tissues
around it, and adjacent teeth should be free from any pathology. Also the gingival
phenotype and scallop should also be adequate.

3.  So the other procedure, socket preservation is a viable option in such situations.
 Since these techniques are almost always combined with bone grafting, primary wound closure
is indispensable.
 This technique employs a combined epithelized-subepithelial connective tissue graft, leaves the
mucogingival line in its place, and has the added advantage of thickening the buccal soft tissue
with the resultant local conversion of a thin marginal gingiva to a thick marginal gingiva.
 The present case report describes the utilisation of horizontal grafting of hard tissue at the same
time as extraction of the tooth and primary closure of the wound with a combined
epithelialized–subepithelial connective tissue graft for socket preservation.

4. CASE REPORT
 A 35-year-old male patient reported to GSL Dental College with the
chief complaint of broken tooth pieces in left upper back tooth region.
 Patient gives no relevant family and medical history.
 General examination and extra oral examination reveals no abnormality.

5.  On intra oral examination, root stumps were present irt 26.
 Patient was diagnosed as having chronic irreversible pulpitis irt 26.
 The patient was informed that the remaining tooth had to be removed
and a detailed description of the surgical and prosthetic treatment
alternatives was presented.
 The patient chose to replace the tooth with an implant supported
prosthesis after 8-10 months.

6.  To prevent bony resorption within the first 3–4 months and to avoid major coronal
advancement flaps, we opted for socket preservation by both hard and soft tissue
grafting by combined epithelialized–subepithelial connective tissue grafts for
optimal implant placement.
 Routine laboratory blood investigations were done and showed no abnormalities.
Surgery was carried out.

7. PROCEDURE
 After achieving adequate anesthesia, the root stumps were
extracted with minor violation to the structures in vicinity.
 The type I (Elian’s socket classification) socket was
meticulously cleaned of inflammatory and granulation tissue
with a curette, and the crevicular epithelium was scraped away
to improve the integration of the soft tissue graft.
BONE GRAFTING:
 Combination of DFDBA and FDBA with 50mg/ml saline
solution are taken in dappen dish and the mixture is prepared.
 Then the mixture is gently grafted into the socket until it
reaches the margins of the bony socket walls.

8. GINGIVAL GRAFTING:
 To close the wound, a combined epithelialized–
subepithelial connective tissue graft with a double pouch
was raised from the hard palate .
 The mesiodistal and vestibulo-oral dimensions of the
extraction socket were measured with a periodontal probe
and transferred to the palate.
 The epithelialized component of the combination graft was
trimmed to adapt its margins precisely to those of the
socket’s mucosa.

9.  The subepithelial component of the graft was as wide as
the mesiodistal dimension of the extraction socket.
 Donor site was sutured and the graft was placed on top
of bone graft and held them in place by suturing.
 Donor site is covered by stent.
 The sutures were removed after 10 days.
 And healing was uneventful.

10. After 1 week After 6 months

11. Pre op Post op
Width and height of the
ridge are maintained

12. DISCUSSION
 Successful implant-supported rehabilitation requires adequate bone volume in all
three dimensions.
 Tooth extractions are, however, inevitably followed by transverse and vertical bony
resorption with resultant loss of soft tissue. As Sharpey’s fibres are torn, the bony
bundle loses its function and is resorbed.
 Loss of bone after extraction, while not preventable, can at least be compensated for
by oversized preservation of the ridge.

13.  The success of grafting critically depends on tight primary wound healing that
keeps bacterial inflammation away.
 A coronal advancement flap produces primary soft tissue closure, but it
displaces the mucogingival junction. Consequently, coronal advancement
flaps should no longer be used for closing fresh extraction sockets.
 Free gingival grafts for sealing extraction sockets were described as early as
in 1994, but as the alveolar gingiva together with the blood clot is the only
blood supply, their failure rate is extremely high.

14.  The high failure and resorption rates of these onlay grafts, among them free
gingival grafts, prompted the development of combined epithelialized–
subepithelial grafts for augmenting edentulous ridges.
 Stimmelmayr et al. used these combined grafts with a single pouch for closing
extraction sockets, and modified them to combination epithelialized–
subepithelial grafts with a double pouch.
 These combination grafts gave lower resorption rates than onlay grafts. In
addition, their optimal bilaminar vascularization derived from the inlay graft
component reduces the failure and dehiscence rates.

15.  This also explains why poor wound healing is rarely seen. Disturbances of wound
healing and dehiscence rates of grafting with resorbable and non-resorbable
membranes are significantly higher.
 Grafting after hard and soft tissue have healed completely invariably requires a
generous flap, and removal of periosteum from the alveolar process, which may
lead to further bony loss. Thickening and stabilizing of the soft tissue is another
benefit.
 In this technique, even though the results of soft tissue healing were excellent, this
technique may require advanced surgical expertise, and cannot be used in periodontally
compromised sites.

16. CONCLUSION
 Preservation of the ridge combined with combined epithelialized–subepithelial
connective tissue grafts for sealing the socket can produce promising results. As
the extraction sockets can be used as access for grafting, incisions can be omitted
and grafting done with minimal invasion.
 However, the limitation of the technique remains as it requires great surgical
proficiency, second surgical site and further studies regarding this technique
should also be undertaken.

17. REFERENCES
 Stimmelmayr M, Güth JF, Iglhaut G, Beuer F. Preservation of the ridge and sealing of the socket with a combination epithelialised and
subepithelial connective tissue graft for management of defects in the buccal bone before insertion of implants: a case series. British Journal
of Oral and Maxillofacial Surgery. 2012 Sep 1;50(6):550-5.
 Landsberg CJ, Bichacho N. A modified surgical/prosthetic approach for optimal single implant supported crown. Part I--The socket seal
surgery. Practical periodontics and aesthetic dentistry: PPAD. 1994 Mar 1;6(2):11-7.
 Stimmelmayr M, Allen EP, Reichert TE, Iglhaut G. Use of a combination epithelized-subepithelial connective tissue graft for closure and
soft tissue augmentation of an extraction site following ridge preservation or implant placement: description of a technique. International
Journal of Periodontics & Restorative Dentistry. 2010 Jul 1;30(4).
 Al Rezk F, Al Rezk M, Al Rezk M, Al Rezk R. The utilization of vascularized pedicle combination epithelial‐sub epithelial tissue graft for
socket preservation in the esthetic zone—A novel approach. Clinical case reports. 2019 Jun;7(6):1139-48.
 Weng D, Stock V, Schliephake H. Are socket and ridge preservation techniques at the day of tooth extraction efficient in maintaining the
tissues of the alveolar ridge? Systematic review, consensus statements and recommendations of the 1st DGI Consensus Conference in
September 2010,... European journal of oral implantology. 2011 Dec 2;4.

18. THANK YOU