3rd Publication IJOI PDF
3rd Publication IJOI PDF
3rd Publication IJOI PDF
2021
Copyright 2021, Quintessence Publishing Company, Ltd.
ORIGINAL ARTICLE
KEY WORDS
aesthetics, bone graft, extraction socket, guided bone regeneration, immediate placement,
vestibular socket therapy
ABSTRACT
Purpose: To assess hard and soft tissues regenerated around immediate implants placed in com-
promised fresh extraction sockets using vestibular socket therapy 2 years postoperatively.
Materials and methods: Twenty-seven compromised fresh extraction sockets were managed
using vestibular socket therapy and immediate implant placement. After immediate implant
placement, a cortical bone shield was stabilised through a vestibular incision. The socket defect
was filled with particulate bone graft. Labial plate thickness and bone height were evaluated
1 and 2 years postoperatively using CBCT. The pink aesthetic score and probing depth were
recorded after 6 months, 1 year and 2 years. A Friedman test was used to study changes in the
reported outcomes over time, with the level of statistical significance set at P ≤ 0.05.
Results: All implants recorded a 100.0% survival rate. A statistically significant increase in bone
height (0.93 mm, P = 0.004) and apical (0.12 mm, P = 0.026), midfacial (1.26 mm, P < 0.001)
and crestal (0.86 mm, P < 0.001) bone thickness was observed after 2 years. The changes in pink
aesthetic score and probing depth were not significant: the pink aesthetic score was 12.48 ± 1.45
and the mean PD was 2.37 ± 0.79 mm mesially, 2.11 ± 0.70 mm facially, 2.07 ± 1.04 mm dis-
tally and 1.00 ± 0.00 mm palatally after 2 years.
Conclusion: Combining immediate implant placement with vestibular socket therapy to manage
compromised fresh extraction sockets offers promising radiographic, aesthetic and periodontal
results while minimising the treatment time and number of surgical procedures required.
profile within a few weeks7. As such, before the membranes placed inside the socket and combined
prosthodontist decides to undertake implant place- with allogeneic bone were used to overcome the
ment, it is mandatory to preserve the established problems posed by the delayed implant placement
deficient bone and soft tissues3,8-12; however, protocol and provided promising short-term results
authors differ in opinion as to whether implants for labial plate thickness21. Assaf et al22 placed
should be placed immediately or whether place- collagen-enriched bovine-derived xenogeneic
ment should be delayed until the bone graft has bone block in a mucoperiosteal pouch dissected to
healed. To avoid poor long-term aesthetic results, extend 3.00 mm apical to the dehiscence defect
some authors precluded immediate implant place- and reported a mean increase in labial bone plate
ment in defective extraction sites10,13. A system- thickness of 2.38 mm. Elaskary et al23 introduced a
atic review by Cosyn et al14 found that the gingival novel technique, namely vestibular socket therapy
phenotype and the degree of damage to the facial (VST), whereby immediate implants were placed in
bone plate were the major risk factors jeopardis- compromised fresh extraction sockets, a vestibular
ing aesthetics and promoting gingival recession. access incision was made and a cortical bone shield
Thus, some authors have recommended delaying was stabilised. The defective socket was filled with
implant placement until the hard and soft tissue particulate bone graft, which was sealed using a
thickness have been increased9,10. Buser et al13 customised healing abutment23. The technique
advocated implant placement 4 to 8 weeks after showed promising results over a 6-month period
extraction and provided additional keratinised regarding soft and hard tissue outcomes23; how-
tissue at the future implant site. Although this ever, a longer follow-up period was required. As
technique demonstrated satisfactory functional such, the present 2-year time series was conducted
and aesthetic outcomes, it required a long treat- to explore the changes in bone height, bone thick-
ment time and multiple surgical interventions that ness, probing depth and pink aesthetic score (PES),
involved flap elevation, thereby increasing the and to investigate the effect of implant site and
risk of gingival recession and loss of the recon- soft tissue grafting on these outcomes when using
structed alveolar ridge8,13,15. Furthermore, Hosny VST and immediate implant placement to restore
and Radi16 expressed doubts about the evidence fresh extraction sockets.
that ridge preservation techniques, regardless of
the materials used, minimise the overall changes
in residual ridge height and width 6 months after Materials and methods
extraction.
As a result of the increased focus on aesthet- The present single-arm clinical study was reported
ics, immediate implant placement has become in accordance with the Transparent Reporting of
the treatment option of choice even in defective Evaluations with Nonrandomized Designs (TREND)
sockets, especially when replacing anterior teeth. guidelines24. It was approved by the ethical com-
Simultaneous socket enhancement and implant mittee at the Faculty of Dentistry, Cairo Univer-
placement in defective sockets was thus intro- sity (REC18.4.20) and conducted in accordance
duced, using a tuberosity bone graft shaped to with the Helsinki Declaration of 1975, as revised
match the labial plate and covered by a connect- in 2013. The study protocol was published on clin-
ive tissue graft, and a mixture of autogenous icaltrials.gov (NCT04332185).
and xenogeneic bone was used to fill the socket A total of 20 adult patients aged ≥ 18 years
gap17,18. The results were not inferior to those were recruited from January to November 2018
achieved with a delayed implant placement proto- from a private clinical practice in Alexandria, Egypt,
col16; however, this approach required autogen- where the intervention and outcome assessment
ous bone grafts, which necessitated longer sur- took place. The participants were included in the
gical time and multiple incisions and increased the study consecutively if they adhered to the follow-
risk of morbidity in the donor site19,20. Collagen ing inclusion criteria:
Fig 1 Vestibular access incision con- Fig 2 Bone shield stabilised to the apical bone using mem-
nected to the socket orifice via a sub- brane tacks.
periosteal tunnel.
• one to three non-adjacent hopeless maxillary (500 mg/100 ml, Amrizole, Amria Pharma, Alex-
anterior teeth with type I and/or II sockets; andria, Egypt). VST was then used to manage
• labial bone plate deficient in width (type I the defects. A 1-cm-long vestibular access incision
sockets) and/or height (type II sockets) and was cut using a 15c blade (Stoma/Storz am Mark,
with the overlying soft tissues intact25. Emmingen-Liptingen, Germany) 3.0 to 4.0 mm
apical to the mucogingival junction of the rele-
Adequate palatal bone and at least 3.0 mm apical vant tooth. A periotome and a microperiosteal
bone needed to be available to engage the imme- elevator (Stoma/Storz am Mark) were used to cre-
diately placed implants and thus achieve optimum ate a subperiosteal tunnel connecting the socket
primary stability (30 Ncm insertion torque) follow- orifice and the vestibular access incision (Fig 1).
ing tooth extraction. Implants (15.0 × 3.8 mm Tapered Pro, Laser-
The exclusion criteria were as follows: Lok collar with resorbable blast texturing [RBT]
• smoking; body, BioHorizons, Birmingham, AL, USA) were
• pregnancy; placed using fully guided surgery. A CAD/CAM
• systemic disease; surgical guide was manufactured using a 3D
• infected sockets; stereolithography (SLA) printer (Form 2, Form-
• chemotherapy or radiotherapy within the pre- labs, Somerville, MA, USA) and used for the pro-
vious 2 years. cedure. This ensured the implants were placed
in the pre-planned positions while engaging 3.0
Eligible patients were informed about the nature to 4.0 mm apical bone. A 0.6-mm-thick flexible
of the study and signed an informed consent cortical membrane shield (OsteoBiol Lamina,
to participate. Preoperative CBCT scans were Tecnoss, Turin, Italy) of heterologous origin was
taken for all patients to ensure the fulfilment of hydrated, trimmed and tacked through the ves-
the abovementioned criteria and to assist with tibular access incision until it extended 1.0 mm
treatment planning for the future implant pos- below the socket orifice. It was then stabilised to
ition and the construction of a computer-gener- the apical bone using membrane tacks (AutoTac
ated surgical guide. If patients were considered System Kit, BioHorizons) (Fig 2). The gap between
eligible, they were given infiltration anaesthesia the implant and the shield/labial plate was then
(Artinibsa 4% 1:100,000, Inibsa Dental, Barce- filled with particulate bone graft (75% autogen-
lona, Spain). The surgical procedure began with ous bone chips harvested from local surgical sites
atraumatic extraction of the compromised tooth and 25% deproteinised bovine bone mineral
and mechanical and chemical debridement of the [DBBM] of equine origin, fully enzyme deanti-
sockets using metronidazole irrigation solution genised [Bio-Gen Mix, Bioteck, Vicenza, Italy]).
Fig 3 Connective tissue grafting of sockets with a thin gin- Fig 4 Customised healing abutment used to create a sealed
gival phenotype. chamber that preserved the bone graft.
a b
Figs 5a-b Soft tissues around the left central incisor (a) 2 months and (b) 2 years after implant placement.
For patients with a thin gingival phenotype, (BruxZir full anatomical zirconia, Glidewell,
determined based on probe transparency as Newport Beach, CA, USA) were cemented after
recommended by De Rouck et al26, soft tissue 2 months (Fig 5). Patients were instructed to take
grafting was performed using a subepithelial 500 mg metronidazole and 500 mg ciprofloxacin
connective tissue graft harvested from the palate (Minapharm Pharmaceuticals, Cairo, Egypt)
using a single incision technique (Fig 3)27. The every 12 hours the day before surgery and for
graft was secured to the inner surface of the soft 5 days after surgery and a non-steroidal anti-
tissue tunnel using 6-0 nylon sutures (Stoma/ inflammatory drug in the form of Catafast 50-mg
Storz am Mark). Finally, the vestibular incision sachets (Novartis, Basel, Switzerland), to use
was secured using the same suture material. A 0.12% chlorhexidine mouthrinse three times
customised healing abutment was used to create daily, to apply cold packs to the operative site
a sealed chamber that preserved the bone graft every 20 minutes for the first 2 hours, and to
(Fig 4) using composite resin (Filtek Supreme adhere to strict oral hygiene measures. Follow-
Ultra Flowable Restorative, 3M, St Paul, MN, up visits were scheduled for 6 months and 1 and
USA) and a temporary abutment (PEEK Tem- 2 years after surgery to record the study out-
porary Cylinder, BioHorizons). The sutures were comes. All soft tissue outcomes were assessed
removed 10 days after surgery and final crowns 6 months (baseline for soft tissues) and 1 and
a b
c d e
Figs 6a-e Bone height and thickness measurements taken after superimposing images of the different follow-up periods. (a) 3D view of the super-
imposed CBCTs; (b) superimposed images in a frontal cut section; (c) thickness and height measurements taken 2 years after implant placement;
(d) measurements taken on the fused sagittal cut section; (e) measurements taken after extraction and after concealing the implant.
2 years postsurgically, and the bone was assessed • Thickness and height of labial bone plate: Images
prior to implant placement and after extraction obtained at baseline and at the 1- and 2-year
(baseline for bone assessment), 1 and 2 years follow-ups were superimposed. Patients were
postsurgically. The outcomes were recorded by radiographed using a wax interocclusal record
two experienced independent examiners (MM to separate the maxillary and mandibular teeth
and AE) and the mean values were recorded for between 5 and 10 kVp. The field of vision was
bone height, bone thickness and probing depth. 6 × 8 mm and the CBCT machine (CS 8100 3D
Interexaminer agreement was 80%. Any dis- System, Carestream Dental, Atlanta, GA) used for
agreement between the examiners regarding the imaging had a high contrast resolution detector
PES was resolved by a third examiner (IR). The (high bit depth). These specifications decreased
study outcomes were as follows: the beam hardening effect. OnDemand 3D soft-
• Implant success as described by Buser et al28: ware (Cybermed, Seoul, South Korea) was used.
Absence of peri-implant infection, persistent Thickness measurements were taken at three
subjective complaints such as pain, foreign levels: at the crestal bone level, at half of the
body sensation and/or dysesthesia, radio- implant length and at the implant apex. Bone
lucency around the implant and/or any detect- height was measured from the implant apex to
able implant mobility. the labial bone plate crest (Fig 6).
Site Variable Soft tissue graft No soft tissue graft Irrespective of soft tissue graft P value
Central incisor Age (y), mean ± SD 41.00 ± 5.06 44.00 ± 10.79 41.43 ± 8.07 0.628
Sex (M/F) 5/2 1/5 6/7 0.103
BH (mm), mean ± SD 10.72 ± 2.17 11.64 ± 2.46 11.73 ± 3.21 0.534
BTA (mm), mean ± SD 3.25 ± 1.17 1.94 ± 0.63 2.99 ± 1.78 0.110
BTM (mm), mean ± SD 0.46 ± 0.32 0.58 ± 0.33 1.91 ± 0.73 0.929
BTC (mm), mean ± SD 0.32 ± 0.35 0.55 ± 0.46 0.46 ± 0.35 0.341
PDM (mm), mean ± SD 1.50 ± 0.55 2.33 ± 0.52 2.11 ± 0.68 0.029*
PDF (mm), mean ± SD 2.00 ± 0.00 2.17 ± 0.75 2.05 ± 0.54 0.611
PDD (mm), mean ± SD 2.00 ± 0.00 1.50 ± 0.55 1.88 ± 0.47 0.032*
PDP (mm), mean ± SD 1.00 ± 0.00 1.00 ± 0.00 1.00 ± 0.00 1.000
PES (range) 12.50 (11.00–14.00) 12.00 (11.00–14.00) 12.44 (11.00–14.00) 0.521
Lateral incisor Age (y), mean ± SD 37.00 ± 7.07 48.20 ± 8.90 41.00 ± 11.45 0.241
Sex (M/F) 2/0 2/3 4/3 0.429
BH (mm), mean ± SD 13.40 ± 0.57 9.87 ± 4.31 11.58 ± 3.68 0.558
BTA (mm), mean ± SD 3.50 ± 1.41 3.46 ± 1.00 3.01 ± 1.27 0.770
BTM (mm), mean ± SD 1.87 ± 0.00 0.38 ± 0.43 0.62 ± 0.07 0.031*
BTC (mm), mean ± SD 0.00 ± 0.00 1.10 ± 1.25 0.76 ± 1.00 0.126
PDM (mm), mean ± SD 3.00 ± 0.00 2.20 ± 1.10 2.22 ± 0.97 0.190
PDF (mm), mean ± SD 1.00 ± 0.00 2.40 ± 0.55 1.88 ± 0.78 0.060
PDD (mm), mean ± SD 2.00 ± 0.00 3.20 ± 1.64 2.44 ± 1.50 1.000
PDP (mm), mean ± SD 1.00 ± 0.00 1.00 ± 0.00 1.00 ± 0.00 1.000
PES (range) 13.00 (13–13) 13.00 (13–14) 13.44 (13–14) 0.176
*Significant at P ≤ 0.05.
BH, bone height; BTA, bone thickness apically; BTC, bone thickness crestally; BTM, bone thickness in middle region; F, female; M, male; PDD, probing
depth distally; PDF, probing depth facially; PDM, probing depth mesially; PDP, probing depth palatally.
Table 2 Results of Friedman test showing the effect of time on the study outcomes
*Significantat P ≤ 0.05. Values with different superscript letters were statistically significant.
NR, not reported.
Table 3 Results of Mann-Whitney U test showing the effect of implant site on the study outcomes
Outcome Time period Central incisor site (n = 18 implants) Lateral incisor site (n = 9 implants) P value Effect size
(d)
Mean ± SD Median (range) Mean ± SD Median (range)
BH (mm) 0–1 y 0.92 ± 2.61 1.00 (−3.10–6.39) 1.49 ± 2.74 1.43 (−1.08–7.86) 0.817 0.089
1–2 y 0.74 ± 2.67 0.67 (−3.40–6.39) 1.30 ± 2.76 0.90 (−1.28–7.66) 0.758 0.119
1–2 y −0.17 ± 0.15 −0.16 (−0.50–0.00) −0.19 ± 0.19 −0.20 (−0.64–0.00) 0.697 0.149
BTA (mm) 0–1 y 0.10 ± 0.26 0.00 (0.00–1.02) 0.33 ± 1.00 0.00 (−1.00–2.00) 0.841 0.059
0–2 y 0.08 ± 0.25 0.00 (−0.09–1.02) 0.20 ± 0.80 0.00 (−1.10–1.50) 0.702 0.119
1–2 y −0.02 ± 0.04 0.00 (0.00–0.00) −0.13 ± 0.23 0.00 (−0.57–0.00) 0.366 0.270
BTM (mm) 0–1 y 1.40 ± 0.57 1.32 (0.28–2.55) 1.51 ± 0.89 1.51 (0.29–2.63) 0.699 0.149
0–2 y 1.24 ± 0.57 1.28 (0.18–2.55) 1.33 ± 0.96 1.41 (0.29–2.60) 0.837 0.079
1–2 y −0.16 ± 0.22 −0.10 (−0.82–0.00) −0.17 ± 0.32 −0.08 (−1.00–0.00) 0.603 0.199
BTC (mm) 0–1 y 1.03 ± 0.61 1.07 (0.04–2.18) 0.72 ± 1.44 1.00 (−2.35–2.25) 0.837 0.079
0–2 y 0.90 ± 0.56 0.97 (−0.03–2.11) 0.64 ± 1.44 0.87 (−2.35–2.15) 1.000 0.000
1–2 y −0.13 ± 0.15 −0.10 (−0.48–0.00) −0.08 ± 0.07 −0.10 (−0.20–0.00) 0.677 0.159
PDM (mm) 0–1 y 0.33 ± 0.69 0.00 (0.00–2.00) 0.00 ± 1.32 0.00 (−2.00–2.00) 0.243 0.383
0–2 y 0.33 ± 0.69 0.00 (0.00–2.00) 0.00 ± 1.32 0.00 (−2.00–2.00) 0.243 0.383
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDF (mm) 0–1 y 0.00 ± 0.59 0.00 (−1.00–2.00) 0.33 ± 1.00 0.00 (−1.00–2.00) 0.395 0.239
0–2 y 0.00 ± 0.59 0.00 (−1.00–2.00) 0.33 ± 1.00 0.00 (−1.00–2.00) 0.395 0.239
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDD (mm) 0–1 y 0.06 ± 0.64 0.00 (−1.00–2.00) −0.11 ± 0.33 0.00 (−1.00–0.00) 0.543 0.159
0–2 y 0.06 ± 0.64 0.00 (−1.00–2.00) −0.11 ± 0.33 0.00 (−1.00–0.00) 0.543 0.159
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PES 6 m–1 y 0.06 ± 0.87 0.00 (−2.00–2.00) −0.44 ± 0.88 0.00 (−2.00–0.00) 0.229 0.341
6 m–2 y 0.00 ± 1.03 0.00 (−3.00–2.00) −0.89 ± 1.17 0.00 (−3.00–0.00) 0.041* 0.668
1–2 y −0.06 ± 0.24 0.00 (−1.00–0.00) −0.44 ± 0.73 0.00 (−2.00–0.00) 0.055 0.468
*Significantat P ≤ 0.05.
NC, not computed (P value could not be computed since the values compared were the same).
preservation of the labial mucosa and under- might be lost after tooth extraction due to the nat-
lying buccal bone are crucial to achieving optimal ural remodelling process15,30. The 100.0% survival
aesthetic results. The combination of osseous re- rate recorded by the technique in defective sockets
generation and soft tissue augmentation has been over a 2-year period, irrespective of the studied
claimed to prevent further bone loss and mucosal region and the socket defect type, is promising
recession, but the results are contradictory3,8,11. and could be attributed to several factors. The use
The present 2-year study showed that VST could of a slowly resorbing flexible labial shield allowed
represent a successful method for managing both for remodelling of the underlying labial bone plate
type I and II socket defects, and could shorten while maintaining the socket dimensions and con-
the treatment time by up to two-thirds of that tours throughout the follow-up period. This also
required for bone grafting and delayed implant explains why there was no significant difference in
placement. Immediate implant placement per se bone height and thickness in the studied regions
could preserve some of the bone volume that 1 and 2 years after implant placement31. A mean
Table 4 Results of Mann-Whitney U test for comparison of the effect of implants placed with and without soft tissue graft on changes in the study
outcomes
Outcome Time period No graft (n = 12 implants) Soft tissue graft (n = 15 implants) P value Effect size
(d)
Mean ± SD Median (range) Mean ± SD Median (range)
BH (mm) 0–1 y 1.31 ± 2.57 1.96 (−3.10–6.39) 0.95 ± 2.74 0.00 (−2.42–7.86) 0.494 0.265
0–2 y 1.12 ± 2.63 1.78 (−3.40–6.39) 0.77 ± 2.76 −0.20 (−2.45–7.66) 0.464 0.285
1–2 y −0.19 ± 0.15 −0.22 (−0.4–0.00) −0.18 ± 0.18 −0.16 (−0.64–0.00) 0.522 0.246
BTA (mm) 0–1 y 0.29 ± 0.62 0.00 (0.00–2.00) 0.09 ± 0.60 0.00 (−1.00–2.00) 0.173 0.412
0–2 y 0.22 ± 0.51 0.00 (−0.09–1.50) 0.04 ± 0.48 0.00 (−1.10–1.43) 0.809 0.075
1–2 y −0.07 ± 0.14 0.00 (−0.50–0.00) −0.05 ± 0.15 0.00 (−0.57–0.00) 0.526 0.189
BTM (mm) 0–1 y 1.70 ± 0.41 1.72 (1.05–2.23) 1.23 ± 0.79 1.13 (0.28–2.63) 0.045* 0.834
0–2 y 1.45 ± 0.48 1.46 (0.51–2.13) 1.13 ± 0.84 1.00 (0.18–2.60) 0.118 0.630
1–2 y −0.24 ± 0.23 −0.18 (−0.82–0.00) −0.10 ± 0.25 −0.03 (−1.00–0.00) 0.002* 1.504
BTC (mm) 0–1 y 1.01 ± 0.51 0.96 (0.20–2.18) 0.86 ± 1.21 1.11 (−2.35–2.25) 0.807 0.094
0–2 y 0.89 ± 0.49 0.85 (0.20–2.11) 0.75 ± 1.18 1.11 (−2.35–2.15) 0.660 0.170
1–2 y −0.12 ± 0.12 −0.1 (−0.40–0.00) −0.11 ± 0.13 −0.10 (−0.48–0.00) 0.882 0.056
PDM (mm) 0–1 y 0.08 ± 0.79 0.00 (−1.00–2.00) 0.33 ± 1.05 0.00 (−2.00–2.00) 0.382 0.285
0–2 y 0.08 ± 0.79 0.00 (−1.00–2.00) 0.33 ± 1.05 0.00 (−2.00–2.00) 0.382 0.285
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDF (mm) 0–1 y 0.25 ± 0.87 0.00 (−1.00–2.00) 0.00 ± 0.65 0.00 (−1.00–2.00) 0.420 0.227
0–2 y 0.25 ± 0.87 0.00 (−1.00–2.00) 0.00 ± 0.65 0.00 (−1.00–2.00) 0.420 0.227
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDD (mm) 0–1 y −0.08 ± 0.51 0.00 (−1.00–1.00) 0.07 ± 0.59 0.00 (−1.00–2.00) 0.589 0.141
0–2 y −0.08 ± 0.51 0.00 (−1.00–1.00) 0.07 ± 0.59 0.00 (−1.00–2.00) 0.589 0.141
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDP (mm) All time periods 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PES 6 m–1 y 0.00 ± 0.00 0.00 (0.00–0.00) −0.20 ± 1.21 0.00 (−2.00–2.00) 0.421 0.227
6 m–2 y −0.08 ± 0.29 0.00 (−1.00–0.00) −0.47 ± 1.51 0.00 (−3.00–2.00) 0.414 0.256
0–2 y −0.08 ± 0.29 0.00 (−1.00–0.00) −0.27 ± 0.59 0.00 (−2.00–0.00) 0.385 0.208
*Significantat P ≤ 0.05.
NC, not computed (P value could not be computed since the values compared were the same).
thickness of 3.12 mm apically, 1.80 mm midfa- than Buser et al13, Lee et al33 and Mazzocco et al34;
cially and 1.37 mm crestally was maintained by the former reported a 0.18-mm reduction in bone
the end of the follow-up period, despite starting height after 1 year, the second a 0.78-mm reduc-
with a mean thickness of 0.55 mm midfacially and tion after a period of 4 to 12 months and the lat-
0.56 mm crestally. The technique does not eliminate ter a 0.5-mm reduction in bone height and width
bone resorption; 0.18 mm bone height and a max- after 6 months. Maintaining bone thickness and
imum of 0.17 mm bone width were lost in the sec- contour was reported to be difficult when using
ond year. These measurements were standardised particulate bone grafts with or without collagen
using OnDemand 3D software that was employed membranes1-4. The latter tend to collapse due to
to superimpose the images captured at the differ- their fast biodegradation by the enzymatic activ-
ent study periods. The measuring technique was ity of the macrophages and polymorphonuclear
proven to be reliable32. The present study recorded leucocytes; this could explain their limited ability
more optimal results for bone height and thickness to preserve bone contour, especially in sites with
Table 5 Results of Mann-Whitney U test for comparison of the effect of type I and II socket defects on changes in the study outcomes
Outcome Time period Type I (n = 13 implants) Type II (n = 14 implants) P value Effect size
(d)
Mean ± SD Median (range) Mean ± SD Median (range)
BH (mm) 0–1 y −1.04 ± 1.03 −0.72 (−3.10–0.34) 3.11 ± 1.96 2.19 (1.43–7.86) < 0.001* 3.225
0–2 y −1.23 ± 1.02 −0.88 (−3.40–−0.10) 2.94 ± 2.04 1.98 (0.90–7.66) < 0.001* 3.225
1–2 y −0.19 ± 0.12 −0.17 (−0.50–−0.03) −0.17 ± 0.20 −0.15 (−0.64–0.00) 0.448 0.293
BTA (mm) 0–1 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.34 ± 0.82 0.00 (−1.00–2.00) 0.041* 0.637
0–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.23 ± 0.68 0.00 (−1.10–1.50) 0.435 0.245
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) −0.11 ± 0.19 −0.05 (−0.57–0.00) 0.004* 0.939
BTM (mm) 0–1 y 1.23 ± 0.80 1.13 (0.28–2.63) 1.63 ± 0.89 1.51 (0.75–2.51) 0.114 0.637
0–2 y 1.19 ± 0.81 1.11 (0.18–2.60) 1.35 ± 0.62 1.37 (0.29–2.51) 0.409 0.322
1–2 y −0.04 ± 0.04 −0.02 (−0.10–0.00) −0.28 ± 0.30 −0.18 (−1.00–0.00) 0.001* 1.644
BTC (mm) 0–1 y 0.57 ± 1.06 0.63 (−2.35–1.77) 1.26 ± 0.73 1.12 (−0.35–2.25) 0.109 0.648
0–2 y 0.50 ± 1.03 0.61 (−2.35–1.66) 1.10 ± 0.74 1 (−0.55–2.15) 0.159 0.563
1–2 y −0.07 ± 0.08 −0.05 (−0.29–0.00) −0.16 ± 0.15 −0.12 (−0.48–0.00) 0.055 0.782
PDM (mm) 0–1 y 0.46 ± 1.13 0.00 (−2.00–2.00) 0.00 ± 0.68 0.00 (−1.00–2.00) 0.105 0.542
0–2 y 0.46 ± 1.13 0.00 (−2.00–2.00) 0.00 ± 0.68 0.00 (−1.00–2.00) 0.105 0.542
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDF (mm) 0–1 y −0.08 ± 0.76 0.00 (−1.00–2.00) 0.29 ± 0.73 0.00 (0.00–2.00) 0.109 0.460
0–2 y −0.08 ± 0.76 0.00 (−1.00–2.00) 0.29 ± 0.73 0.00 (0.00–2.00) 0.109 0.460
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDD (mm) 0–1 y 0.16 ± 0.69 0.00 (−1.00–2.00) −0.14 ± 0.36 0.00 (−1.00–0.00) 0.197 0.341
0–2 y 0.15 ± 0.69 0.00 (−1.00–2.00) −0.14 ± 0.36 0.00 (−1.00–0.00) 0.197 0.341
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDP (mm) All time 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
periods
PES 6 m–1 y −0.23 ± 1.01 0.00 (−2.00–2.00) 0.00 ± 0.78 0.00 (−2.00–2.00) 0.404 0.235
6 m–2 y −0.46 ± 1.27 0.00 (−3.00–2.00) −0.14 ± 1.03 0.00 (−3.00–2.00) 0.417 0.254
1–2 y −0.23 ± 0.60 0.00 (−2.00–0.00) −0.14 ± 0.36 0.00 (−1.00–0.00) 0.875 0.037
*Significantat P ≤ 0.05.
NC, not computed (P value could not be computed since the values compared were the same).
Table 6 Results of Friedman test showing the effect of time on the study outcomes in type I sockets
*Significant at P ≤ 0.05. Values with different superscript letters were statistically significant.
Table 7 Results of Friedman test showing the effect of time on the study outcomes in type II sockets
BH (mm) 9.76 ± 3.51 10.74 (3.50–14.57)b 12.87 ± 2.04 13.20 12.70 ± 2.00 12.72 < 0.001* 1.003
(9.50–16.23)a (9.50–16.00)a
BTA (mm) 3.17 ± 1.84b 3.04 (0.44–7.76) 3.51 ± 1.79a 3.41 (1.46–7.76) 3.40 ± 1.76a 3.36 (1.36–7.76) 0.026* 0.260
BTM (mm) 0.66 ± 0.71b 0.48 (0.00–1.87) 2.29 ± 0.98a 2.09 (1.26–3.98) 2.00 ± 1.01a 1.76 (0.73–3.81) < 0.001* 0.983
BTC (mm) 0.28 ± 0.54b 0.00 (0.00–1.87) 1.54 ± 0.63a 1.55 (0.53–2.87) 1.38 ± 0.64a 1.36 (0.53–2.80) < 0.001* 0.745
PDM (mm) 2.29 ± 0.83 2.50 (1.00–3.00) 2.29 ± 0.73 2.00 (1.00–3.00) 2.29 ± 0.73 2.00 (1.00–3.00) 0.717 0.024
PDF (mm) 1.93 ± 0.62 2.00 (1.00–3.00) 2.21 ± 0.58 2.00 (1.00–3.00) 2.21 ± 0.58 2.00 (1.00–4.00) 0.135 0.143
PDD (mm) 2.43 ± 1.09 2.00 (2.00–5.00) 2.29 ± 1.20 2.00 (1.00–5.00) 2.29 ± 1.20 2.00 (1.00–5.00) 0.135 0.143
PDP (mm) 1.00 ± 0.00 1.00 (1.00–1.00) 1.00 ± 0.00 1.00 (1.00–1.00) 1.00 ± 0.00 1.00 (1.00–1.00) NC NC
PES 12.86 ± 1.03 13.00 (11.00– 12.86 ± 1.03 13.00 12.71 ± 1.20 13.00 0.497 0.050
14.00) (11.00–14.00) (10.00–14.00)
*Significant at P ≤ 0.05. Values with different superscript letters were statistically significant.
NC, not computed (P value could not be computed since the values compared were the same).
high muscular and frenular activity such as the cen- and height were not statistically significant, except
tral incisor site35. Furthermore, vertical releasing for midbuccal bone thickness. The baseline charac-
incisions and full-thickness flap reflections, often teristics reveal that this difference existed from the
performed in grafted healed sockets augmented beginning in this region, favouring the grafted sites.
with collagen membranes, are associated with The midfacial region of the implant was specifically
postoperative mucosal recession36. On the other involved, since the dimensional alteration pattern
hand, the use of titanium mesh to preserve the in single extraction sites with healthy neighbouring
contour of the reconstructed defect could cause dentition was shown to occur mainly in the central
complications due to secondary wound closure, area of the socket wall40. This could also explain
flap dehiscence and the need for a second surgical why there was a significant difference between
procedure to remove the barrier31. Another factor the bone thickness changes in type I and II sockets
that contributed to the success of VST was the use in this specific region after 2 years. Significant dif-
of particulate bone graft composed of a mixture ferences between bone thickness changes in both
of deproteinised and autogenous bone harvested socket types were also observed apically, as no
from the local surgical site. This enhanced osteo- changes were found in type I sockets, in contrast
inductivity has been found to boost bone regen- to the significant changes seen in type II sockets
eration and eliminate the need for a donor site, due to the added value of VST in this socket type in
thus decreasing the comorbidity of the latter and particular. The technique also achieved a relatively
reducing pain and annoyance to the patient20,37. stable bone height for type II sockets, as dem-
Furthermore, a vestibular access incision was made onstrated by the insignificant difference between
to ensure stabilisation of the labial shield; this is type I and II sockets and the insignificant changes
essential for successful bone regeneration38. This in bone height and thickness of type II sockets
was augmented by connective tissue grafting in in the second year of follow-up. This was also
type II sockets exhibiting a thin biotype. In these reflected in the results for PES and probing depth,
cases, the soft tissue graft counteracted the det- which showed an insignificant difference between
rimental effect of the thin gingival phenotype type I and II sockets.
on horizontal bone loss39 and midfacial mucosal The success of VST was further ensured by the
recession, as evidenced by a systematic review by flapless computer-guided implant placement tech-
Cosyn et al14. As a result, the differences between nique. The buccal bone plate, which is < 1.0 mm
grafted and non-grafted sites for bone thickness thick in most cases5-6, receives its blood supply
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Abdelsalam Elaskary
Correspondence to:
Prof Iman Abd-ElWahab Radi, Faculty of Dentistry, Cairo University, 11 El-Saraya St, El Manial, Cairo 11553, Egypt.
Email: iman.abdelwahab@dentistry.cu.edu.eg
Literature abstract
Int J Periodontics Restorative Dent 2020;41:589–597.
Karcı B, Öncü E, Dogan M. The effect of different dental implant surface characteristics on
bone immunologic biomarkers and microbiologic parameters: a randomized clinical study.
This study assessed the levels of tumor necrosis factor-_ (TNF-_), prostaglandin E2 (PGE2), receptor
activator of nuclear factor kappa B (RANK), RANK ligand (RANKL), osteoprotegerin (OPG), and levels
of Fusobacterium nucleatum, Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia,
Prevotella intermedia, and Streptococcus oralis in areas where airborne particle-abraded, large-grit,
acid-etched (SLA), fluorine-modified, and anodized implant surfaces are used. A total of 71 implants
from 37 patients were assessed, grouped according to the surface characteristics of the implants: SLA
surface (Group 1), fluorine-modified surface (Group 2), and anodized surface (Group 3). The following
clinical indices were measured: Gingival Index (GI), probing depth (PD), bleeding on probing (BOP),
clinical attachment level (CAL), and keratinized tissue width (KTW). Peri-implant sulcus fluid and sub-
gingival plaque samples were also collected. Commercial enzyme-linked immunosorbent assay (ELISA)
kits were purchased for measuring TNF-_, PGE2, RANKL, RANK, and OPG. Real-time quantitative
polymerase chain reaction (PCR) was used to detect P intermedia, T forsythia, T denticola, F nuclea-
tum, P gingivalis, and S oralis levels in the subgingival biofilms. The groups showed no statistically
significant differences in GI, PD, BOP, CAL, KTW, or peri-implant status. The total amounts of PGE2,
TNF-_, RANKL, RANK, and OPG and the RANKL/OPG ratio were not significantly different between
groups. F nucleatum, T forsythia, P intermedia, P gingivalis, and T denticola were significantly higher
in Group 3 implants. DNA concentrations of S oralis were higher in Group 2. Within the limitations of
this study, SLA and fluorine-modified implant surfaces may be more clinically successful than anodized-
surface implants. © 2020 Quintessence Publishing Co, Inc.