Update in clinical procedures
The soft tissue solution
There are several well-known techniques used to compensate for tissue changes following tooth extraction (Chappuis et al., 2017). Of these, the most commonly used is to rebuild the buccal part of the socket by bone grafting. Since the mid-90s, however, different soft tissue techniques have been proposed to build up the lost volume and seal the socket. A recent RCT compared CBCT images of guided bone regeneration (GBR) and soft tissue grafting, and concluded that both procedures were equally effective in the short term (De Bruyckere et al., 2018). On the other hand, however, a lower percentage of mineralisation has been observed in sockets where biomaterials are used (12%) compared with natural healing (50–60%) (Araujo et al., 2015).
The approach presented here by the speaker, for immediate implant placement in a defective socket with buccal bone wall loss, is based on a similar approach: let the socket heal naturally and protect it with a soft tissue graft. The implant should be placed palatally, allowing the blood clot to occupy the buccal space and form new bone. Next, a connective tissue graft is performed using a bilaminar tunnelling technique. This graft compensates for the loss of buccal volume and seals the socket (fig 10).
The speaker said he realises that this approach may be viewed as controversial, as it doesn’t pretend to fully recover the bone loss. But, he stated, we must accept that it can successfully maintain the total buccal volume of the socket, allowing us to opt for an immediate restoration.
Technically, the critical step in this technique is to create an adequate bilaminar bed for the soft tissue graft in a mean buccal mucosa thickness of 0.6mm. Part of the connective tissue graft is left exposed, to close the socket. The speaker showed several successful cases with 5–6 years of follow-up (which were progressively more difficult and complex); he also showed some recent cases with promising results (fig 11–12).
In cases involving extensive damage to the buccal bony wall, a second connective tissue graft may be needed. This technique – compensating alveolar socket seal (CASS) – has been used in 389 consecutive patients in the last ten years, on 414 implants, without biomaterials, with a 98.8% survival rate. Re-grafting with another CTG was needed in only 11 cases (data non published yet).
The speaker summarised the pros and cons of the CASS technique thus:
- Advantages: it maintains buccal volume and controls the height of buccal margin. There is no need for foreign material, thus promoting natural socket healing. It has reduced cost and associated chair time
- Disadvantages: it requires a second surgery site, specific microsurgical instruments and has a steep learning curve. It is a sensitive technique that should be classified as complex-advanced (Buser et al., 2017)