aesthetic and patient preference using a bone substitute to preserve extraction sockets under...

7/31/2019 Aesthetic and Patient Preference Using a Bone Substitute to Preserve Extraction Sockets Under Pontics. a Cross-se

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Eur J Oral Implantol 2009;2(3)209217

CLINICAL ARTICLE

Purpose: To evaluate aesthetic and patient satisfaction after tooth extraction using a bone substitute

(and soft tissue grafting when tissue thickness was lacking) under a pontic to preserve the alveolar

ridge for aesthetic purposes. The contralateral natural tooth acted as internal control.

Materials and methods: All patients with at least one site under a pontic augmented with Bio-Oss or

Bio-Oss Collagen with or without a concomitant connective tissue graft with at least a follow-up of 6

months after the ridge preservation procedure were eligible for the present retrospective study. Sites with

a damaged buccal wall were excluded. Outcome measures were: aesthetics (pink esthetic score, PES)

evaluated by an independent and blinded dental hygienist on the basis of clinical pictures, patient sat-

isfaction, patient preference and complications.

Results: Twenty-six patients were consecutively treated, and 23 patients attended the evaluation visit.

In seven patients, soft tissue grafts were performed in conjunction with Bio-Oss placement. Eight to

86 months after the ridge augmentation procedure (mean 38 months), there were no statistically sig-

nificant differences observed in PES between preserved sites and control teeth. Patient satisfaction did

not show any statistically significant difference between the two groups either. All patients declared

they would undergo the same procedure again.

Conclusions: Bio-Oss placement in post-extractive sites with a remaining buccal bone plate lead to a

good aesthetic result. Randomised clinical trials with suitable control groups are needed to identify the

most effective techniques and/or materials to preserve ridges under pontics.

Markus Schlee, Marco Esposito

Aesthetic and patient preference usinga bone substitute to preserve extraction sockets

under pontics. A cross-sectional survey

aesthetic, bone substitutes, observational study, pontic ridge preservationKey words

Markus Schlee, DSpecialist in Periodonto

Private practice, Forchh

Germany

Marco Esposito, DPhD

Senior Lecturer, Oral anMaxillofacial Surgery, S

of Dentistry, The Unive

of Manchester, UK and

Associated Professor,

Department of Biomat

The Sahlgrenska Acade

at Gteborg University

Sweden.

Correspondence to:

Dr Marco Esposito

School of Dentistry, Or

and Maxillofacial Surge

The University of

Manchester, Higher

Cambridge Street,

Manchester, M15 6FH

E-mail:

espositomarco@hotma

Introduction

After tooth extraction, the alveolar bone remodels and

resorbs1-4. Two-thirds of this reduction occurs within

the first 3 months and within 1 year the clinical width

of the alveolar ridge is reduced by approximately

50%1-4. The mean vertical loss of tissues at single

extracted sites ranges between 1 to 4 mm1-4, depend-

ing on site location. This physiological phenomenon

occurs at different rates and degrees among various

individuals and in some cases it can be very pro-

nounced1-4. In sockets previously damaged by trauma


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or chronic inflammatory processes, bone resorption

may be more pronounced. Localised alveolar bone

resorption does not affect the possibility of placing a

conventional bridge for replacing the lost dentition,

but may affect aesthetics and the possibility of placing

dental implants. Particularly in aesthetic areas and in

those patients exposing visible portions of gum when

speaking and smiling, the resorbed alveolar crest could

be a cause of social discomfort and embarrassment.

Various techniques are currently used for ridge

preservation or reconstruction, ranging from softtissue grafts to augmentation with bone grafts and/or

bone substitutes1,3-15. Despite numerous publications

on this topic, the number of reliable randomised con-

trolled trials is rather limited1,4,13.

The aim of this cross-sectional survey was to evalu-

ate aesthetic and patient satisfaction after tooth extrac-

tion using a bone substitute (and soft tissue grafting

when tissue thickness was lacking) under a pontic to

preserve the alveolor ridge for aesthetic purposes. The

contralateral natural tooth served as internal control.

This study is reported following the STROBE Statement

(http://www.strobe-statement.org/) for observational

studies.

Materials and methods

This investigation was designed as a cross-sectional

survey including consecutively treated patients who,

at recall, were informed about the study procedure

and signed a written informed consent form. Allpatients who underwent a procedure of ridge preser-

vation after tooth extraction with Bio-Oss (Geistlich

Pharma AG, Wolhusen, Switzerland) with or without

soft tissue grafting between 1 January 2001 and

30 September 2008 at a German private dental prac-

tice by a single operator (Markus Schlee) and having

a follow-up of at least 6 months after the ridge preser-

vation were considered to be eligible for this study. In

cases of several augmented sockets in the same

patient, only one site was randomly selected for each


210 Schlee/Esposito Aesthetic and patient preference using a bone substitute

Table 1 Decision tree for soft tissue grafting.

Socket

Thick biotype Thin biotype

No recession Recession No recession Recession

Socket sealwith pontic

Socket seal with connective tissue graft


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patient by drawing a lot. The selected socket had tobe under a pontic element. The corresponding con-

tralateral natural tooth acted as a control (e.g. if the

socket of tooth 14 was preserved, its control was the

tooth in position 24). If the contralateral tooth was

missing, the contralateral tooth most similar to the test

site was chosen. In the case where the only aug-

mented site was a central incisor, the contralateral lat-

eral incisor was chosen as control to avoid evaluation

of two adjacent teeth.

To be treated for ridge preservation, the patients

had to be 18 years or older and require the removal or

one or more teeth that were going to be rehabilitated

with a fixed partial denture. Exclusion criteria were:

pregnancy, denture systemic diseases, smoking of

more than 10 cigarettes per day, sites with acute infec-

tion or not in aesthetic areas or not under pontic ele-

ments, and lack of patient interest in the preservation

procedure.

The clinical procedures were the following: after

local anaesthesia with Ultracain D-S forte (articaine

hydrochloride, adrenaline hydrochloride, 1:100,000,Hoechst, Frankfurt, Germany), the periodontal fibres of

the tooth to be extracted were dissected with a sharp

blade (PFISCHLEE, Hu-Friedy, Chicago, USA) as far

subcrestally as possible. Great care was taken to pre-

serve the buccal bone. After being mobilised, the teeth

were extracted as gently as possible with appropriate

forceps. Granulation tissue and sulcular epithelium

were carefully removed with sharp spoons and a blade

(Lucas CL84, Hu-Friedy). After being moistened with

blood, Bio-Oss or Bio-Oss Collagen was used as bone

filler. Bio-Oss is composed of particles of deproteinisedbovine-derived bone mineral to which collagen can be

added (Bio-Oss Collagen). The material was discreetly

condensed to the crestal edge of the bone. The choice

between Bio-Oss or Bio-Oss Collagen was based on

the clinicians preference for clinical handling.

Connective tissue grafts (CTG) were performed in

the presence of thin gingival biotypes or gingival

asymmetries like recessions (Table 1 and Fig 1). An

undermining tunnelling technique starting in the

sulcus was used. The split flap exceeded the mucogin-

gival junction apically to get a sufficient mobilisation

of the flap. A CTG harvested from the palate was

inserted under the periosteum to thicken the tissue on

the buccal aspect, to close the extraction site and to

balance soft tissue dehiscence in the sulcular area

(Fig 2). 6-0 Premilene (Braun, Melsungen, Germany)

sutures were used to close the wounds. Only a slight

contact between the CTG and the provisional restora-

tion was allowed to avoid necrosis in case of swelling.

Sutures were removed after 7 days. After 6 weeks the

temporary prosthesis was removed and a cavity wasprepared in the gingiva according the shape of a mod-

ified ovate pontic (mOP). The temporary prosthesis

was adapted to the cavity with light-curing compos-

ites and then carefully polished. The profile of the

mOP differs from a regular ovate pontic16-18. The sur-

faces bucally and proximally are flat, and the edges are

just a little bit rounded. The lingual aspect is shaped

conventionally. This supports the tissue and may result

in a better and more natural shape of the pseudo-

sulcus and the papillae (Fig 3).


Schlee/Esposito Aesthetic and patient preference using a bone substitute

Fig 1 Thin biotype and gingival asymmetry prior to extrac-tions.

Fig 2 After extraction of the maxillary incisors, two implantswere placed in the sockets of the lateral incisors, a connec-tive tissue graft was slipped underneath a tunnelling splitflap and extraction sockets of the central incisors were filledwith Bio-Oss Collagen.


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In presence of thick biotypes and harmonious gin-

gival levels, no soft tissue graft was implemented and

the Bio-Oss was kept in place with the mOP (Figs 4

to 8). A certain migration of Bio-Oss granules occurred

(Fig 9). Temporary prostheses were removed every 4

weeks to eliminate the embedded Bio-Oss granules

until any migration came to an end (Fig 10).

After a healing period of 6 months (Figs 11 and

12) impressions for the final restorations were

taken. Major efforts were taken to preserve the



Fig 3 The gingiva was shaped with a modified ovate pon-tic.

Fig 4 Clinical situation before extraction.

Fig 5 X-rays before extraction demonstrate the residualbone level.

Fig 6 The extraction sockets were filled with Bio-OssCollagen.

Fig 7 The socket was filled to the crestal edge to minimiseparticle migration into the soft t issues.

Fig 8 Grafts were kept in place by modified ovate pontics.


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gained soft tissue contour for the impression. To

reproduce the gained soft tissue profile, the frame

was lined with polyether (Impregum, 3M ESPE,

Neuss, Germany) and the stone casts were adapted

by the dental technician. Final restorations were

accurately polished before and after glazing to

obtain a smooth and homogenous surface in con-

tact with the soft tissues.

Patients were identified electronically by browsing

the patient database with a search tool by a dental

assistant (Ulrike Huemmer) using the keywordssocket preservation. It was decided to include in the

present study only patients having preserved buccal

bone at the extraction sites, therefore 11 patients not

fulfilling this requirement were not included in the

study or evaluated. All eligible patients were recalled

to attend the dental practice for the evaluation. It was

annotated if a patient could not be contacted or

refused to attend the follow-up assessment. In that

case, the reason of the refusal was noted. Outcome

measures were the following.

Aesthetics were evaluated using the pink esthetic

score (PES)19. At the recall visit, two clinical pic-

tures (one vestibular and one occlusal digital pho-

tograph) were taken, including both adjacent

teeth of both the test and control sites under the

same light conditions and using similar framing

(Fig 13). Once all pictures were collected, an

independent and blinded trained dental hygien-

ist (Tatjana Huck) scored the pictures visualised

on a computer screen for aesthetics. In brief,

seven variables were evaluated: mesial papilla,distal papilla, soft tissue level, soft tissue contour,

alveolar process deficiencies, soft tissue colour

and texture. A 0-1-2 scoring system was used, 0

being the lowest and 2 being the highest value,

with a maximum achievable score of 1419.

Patient satisfaction: at the recall appointment, an

independent outcome assessor (Ulrike Huem-

mer) provided a mirror to the patients to show

both test and control teeth on which patients had

to express their opinions and were asked are you



Fig 9 Some Bio-Oss particles migrated trough the gingivaand were removed after 8 weeks.

Fig 10 No inflammation was visible after 12 weeks.

Fig 11 The provisional restoration shaped and maintainedboth papillae and sulci.

Fig 12 Volume of the ridge was maintained after 6 months.


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satisfied with the aesthetic outcome of the gum

surrounding this tooth? Then, indicating only

the preserved site, the outcome assessor asked

Would you undergo the same procedure again?

Possible answers were: i) definitively yes, ii) yes,

iii) uncertain, iv) no and v) absolutely not. The

questions were always posed with exactly the

same wording.

Patient preference: patients were asked which of

the two sites they preferred, focussing their

attention to their gums. Possible answers were:i) the augmented site, ii) the natural site, iii) both

are equally nice and iv) both are equally bad.

Data analysis was carried out according to a pre-

established analysis plan. A biostatistician with

expertise in dentistry analysed the data, without

knowing the group codes. Differences in PES and

patient satisfaction (ordinal data) were compared

between groups using the Wilcoxon signed-rank test.

Patient preference was calculated with odds ratios

(OR) between patients preferring the preserved site

and those preferring the natural control site using the

McNemar test. All statistical comparisons were

conducted at the 0.05 level of significance.

Results

A total of 26 patients with preserved buccal bony wall

were consecutively treated. Three patients (12%) did

not want to attend the recall visit (dropouts). Of theattending patients, 20 (87%) were females and three

(13%) males. Age at the time of the preservation pro-

cedure ranged from 29 to 69 years (mean 53 years).

Eighteen patients (78%) declared themselves to be

non-smokers and five (22%) to be smokers. In 16

(70%) patients the socket was filled with Bio-Oss only,

whereas in seven (30%) patients the sites were also

augmented with a soft tissue graft. Follow-up ranged

from 8 to 86 months after the preservation procedure

(mean 38 months). The location of the preserved sites



Fig 13 13 Examples of clinical pictures scored for aesthetics using the pink esthetic score (PES): a) frontal picture of a pre-served post-extractive site (canine) under a pontic, b) occlusal picture, c) anterior picture of the contralateral canine that act-ed as intra-individual control and d) occlusal picture.

a

c

b

d


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and their control contralateral natural dentition is illus-

trated in Table 2.

Frequencies for PES assessed at preserved and con-

trol sites by an independent and blinded hygienist are

illustrated in Table 3. There were no statistically signif-

icant differences in PES between preserved and con-trol sites (Wilcoxon signed-ranks test P = 0.248).

The degree of patient satisfaction with respect to

the aesthetic outcome at both preserved and control

sites can be seen in Table 4. There were no statistically

significant differences with respect to aesthetics

according to patient opinion between preserved and

the control sites (Wilcoxon signed-rank test

P = 0.527). All patients declared that they would do

the ridge preservation again. Fifteen patients (65%)

replied with a definitively yes and eight patients

(35%) with a yes.Patient preferences between preserved and con-

trol sites are summarised in Table 5. There was no sta-

tistically significant difference with respect to patient

preference (OR 0.43, 95% CI 0.07 to 1.88; McNe-

mar test P = 0.34), with trends favouring preserved

sites.

Discussion

The main finding of the present study was that,

between 8 and 86 months after the ridge preservation

procedure (mean 38 months), no statistically signifi-

cant differences could be found in PES and patient sat-

isfaction when comparing post-extraction sites with

intact buccal bone filled with granular Bio-Oss under

pontics with their natural contralateral dentition. This

is a positive result indicating that this type of ridge

preservation procedure can lead to a good aesthetics

as evaluated by both an independent and blinded out-

come assessor and the patients themselves. This is inagreement with other studies showing that various

preservation techniques can reduce ridge resorp-

tion1,3,4,9, even though some preservation techniques

are associated with a substantial number of failures

and complications3 20,21 or they appear to be ineffec-

tive7.

No membranes were used in the present study,

since they were not shown to have any advantages

when used over a bone substitute in the case of socket

preservation8.



Site position(tooth position)

Number ofpreserved sites(%)

Number ofcontrol sites(naturaldentition) (%)

11 5 (22) 4 (17)

12 2 (9) 3 (13)

13 2 (9) 4 (17)

14 0 (0) 1 (4)

15 1 (4) 0 (0)

21 5 (22) 2 (9)

22 3 (13) 5 (22)

23 4 (17) 2 (9)

25 0 (0) 1 (4)

35 1 (4) 0 (0)

45 0 (0) 1 (4)

Table 2 Location opreserved sites andtheir control contraeral natural dentitio

Pink estheticscore



9 0 (0) 1 (4)

10 0 (0) 1 (4)

11 2 (9) 2 (9)

12 8 (38) 6 (26)

13 6 (26) 8 (35)

14 7 (30) 5 (22)

Table 3 Frequencifor the pink esthetscore at preservedcontrol sites. No sttically significant dferences were foun

Degree ofaestheticsatisfaction



Definitively satisfied 12 (52) 15 (65)

Satisfied 11 (48) 7 (30)

Uncertain 0 (0) 1 (4)

Table 4 Frequencifor aesthetic satisftion expressed by patient at preserveand control sites. Npatient expressed negative evaluatio

No statistically signcant differences wfound.

Patient preference Number of patients (%)

Preserved site 7 (30)

Control site 3 (13)

No preference (both nice) 13 (57)

Table 5 Frequenciefor patient preferenbetween preservedcontrol sites. No patient was dissatisfiewith both sites. Notistically significantferences.


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The major limitations of the present investigation

were the small sample size, the retrospective design

and the relatively high drop-out rates. Ideally, prospec-

tive studies with larger sample sizes should be con-

ducted. Retrospective studies are not the ideal study

design to evaluate efficacy of interventions22

, never-theless they can still provide some valuable informa-

tion. Randomised controlled clinical trials (RCTs) are

the gold standard to evaluate the efficacy of medical

interventions. So far a few RCTs have been published

evaluating various ridge preservation techniques1,4

showing that they are effective in minimising ridge

resorption.

A drop-out rate of 12% is acceptable. Several calls

were made to invite all patients to attend the evalua-

tion visit, but three patients expressed no intention to

attend. This is an observational study that included acohort of patients selected retrospectively. Patients

were not informed initially that they would be

assessed, as it happens in prospective studies, there-

fore patients that could have refused participation in

the study, were counted anyway and this could explain

why three patients refused to attend the evaluation

visit. Another possibility is that they were unsatisfied

with the outcome of the ridge preservation and

decided not to attend. Unfortunately, the patients did

not provide sufficient information to make an

informed opinion, so the reasons why they refused to

attend remain purely conjectural.

To date, this is the only study in which preserved

post-extractive sites under pontics were compared

with their contralateral natural teeth using aesthetic

assessments. This choice was dictated at protocol for-

mulation when it had to be decided which would have

been the control sites, as contralateral dentition was

the only available option.

The results of the present study can be extrapo-

lated to comparable patient populations if similar inter-ventions are provided by experienced professionals.

However, it should be emphasised once more that in

the present study only post-extractive sockets having

preserved buccal bone were included. Consequently,

these results may not apply to damaged extraction

sockets.

Conclusions

Placement of Bio-Oss in well-preserved post-extrac-

tion sites, sometimes in conjunction with soft tissue

augmentation, was associated with good aesthetics as

judged by an independent blinded hygienist andpatients themselves when compared with contralat-

eral sites with natural dentition. Randomised clinical

trials with suitable control groups are needed to iden-

tify the most effective techniques and/or materials to

preserve post-extractive sites under pontics.

Acknowledgements

The authors wish to thank Tatjana Huck (dental

hygienist) for serving as blinded outcome assessor forthe aesthetic outcome, and Ulrike Huemmer (dental

assistant) for identifying the patients and recording

their satisfaction and preference. This study was not

sponsored in the sense that free material was given,

however it was initiated on the request of Geistlich

Pharma AG.

References

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