What factors really matter?
An overview of Treatment of Extraction Sockets: A New Classification by Prof Ki-Tae Koo
Post-extraction management in the past predominantly consisted of “spontaneous healing”, when the socket was simply allowed to heal without intervention. Extraction socket management, commonly referred to as ridge preservation, was only genuinely considered by clinicians who placed implants.
Recent evidence has shown that the process of extracting a tooth initiated the bone remodelling process almost immediately. Some processes are irreversible, such as the loss of bundle bone post-extraction – which is a functionally-dependent bone structure that surrounds the tooth,1and thus the loss of over alveolar ridge dimension both in vertical and horizontal aspects is inevitable. Spontaneous healing has been shown to lead to a loss of ridge width of 40-50% within 12 months, with two-thirds of these changes occurring in the first 3 months.2,3The development of grafting materials has changed the way we view this scenario however, with morphological changes evident post-extraction significantly reduced with adequate socket management techniques using grafting materials, such as Geistlich Bio-Oss® and Geistlich Bio-Oss® Collagen. This remodelling process can be modified favourably for more predictable restoration, which is more stable and aesthetically satisfactory. As our understanding of socket preservation techniques evolved, so did the idea that these techniques are not only essential for maintaining hard tissue, but also soft tissue.
Work by the Osteology Consensus Group in 2011 provided guidance that indicated the need for adequate ridge preservation existed in order to maintain the existing soft and hard tissue envelope, whilst also looking to simplify subsequent treatment procedures.4This was supported by Dr Dietmar Weng’s work and his colleagues, which identified that the need for secondary bone augmentation was 10 times greater when ridge preservation was not performed at the time of tooth extraction.5There is a mountain of evidence now that identifies the benefit of performing ridge preservation. However, it’s important to recognise that all sockets should not be considered equal. When you come across certain situations – how can they be assessed, and an adequate treatment option chosen?
Various classiﬁcation systems relating to extraction socket management have been proposed thus far in order to simplify the decision-making process and provide guidance on the timing of implant placement. The use of such classifications and evaluation of the situation can only occur immediately following extraction, in part due to both the damage done during the extraction, and the fact that periodontal structures often covers hard-tissue architecture.6Unfortunately, many of these previous classification systems focus on the anterior teeth.6-10In a real-world situation, different types of sockets should not solely be based on defect location. Information regarding both soft and hard tissue breakdown and the number of remaining walls of the socket is crucial for determining the appropriate treatment protocol.
Prof Ki-Tae Koo, and his colleagues at Seoul National University, Dr Jung-Ju Kim and Dr Heithem Ben Amara, have looked at categorising extraction sockets impaired due to chronic pathology in to groups based on factors such as residual bone morphology and soft tissue height. As a result, the authors have identified 5 distinct “types” (6 separate groups) of extraction socket classifications that are applicable to all clinical situations (Fig 1).
The easy-to-follow classifications and associated descriptions provide clinicians with treatment options/suggestions for each type of socket described, with a suggestion for the ideal timing of implant placement and predictability of the implant and ridge preservation potential provided, based on scientific background and clinical experience. The use of diagrams, radiographic imaging and photographs in conjunction with one another (Fig 2) provides readers with a thorough overview of each socket type described by the authors, and what the various presentations could be.
The use of this objective method of evaluation in clinical practice will hopefully lead to greater long-term implant stability and more predictable aesthetic outcomes. The guidance provided in terms of which Geistlich products to use within the specific situation, time of implant placement, predictability and ridge preservation potential will provide both inexperienced and experienced clinicians with a robust and useful resource for ridge preservation in a number of situations.
Please contact Geistlich Pharma AU on 1800 776 326 to obtain your copy of Prof Koo’s Treatment of Extraction Socket: A New Classification and/or to discuss your extraction management options with one of our product specialists.
- Araujo MG et al., Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005; 32: pp212.
- Schropp L et al., Bone Healing and Soft Tissue Contour Changes Following Single-Tooth Extraction: A Clinical and Radiographic 12-Month Prospective Study. Int J Periodontics Restorative Dent 2003; 23: pp313.
- Jung RE et al., Radiographic evaluation of different techniques for ridge preservation after tooth extraction: a randomized controlled clinical trial. J Clin Periodontol 2013; 40: pp90.
- HämmerleCH, et al Osteology Consensus Group 2011. Evidence-based knowledge on the biology and treatment of extraction sockets. ClinOral Implants Res. 2012 Feb;23 Suppl 5:80-2. doi: 10.1111/j.1600-0501.2011.02370.x.
- WengD et al., Are socket and ridge preservation techniques at the day of tooth extraction efficient in maintaining the tissues of the alveolar ridge?Eur J Oral Implantol. 2011;4 Suppl:59-66
- Caplanis N, Lozada JL, Kan JY. Extraction defect assessment, classification, and management. J Calif Dent Assoc 2005;33:853-863.
- Funato A et al., Timing, positioning, and sequential staging in esthetic implant therapy: a four-dimensional perspective. Int J Periodontics Restorative Dent 2007;27:313-323.
- Elian N, Cho SC, Froum S, Smith RB, Tarnow DP. A simplified socket classification and repair technique. Pract Proced Aesthet Dent 2007;19:99-104.
- Smith RB, Tarnow DP. Classification of molar extraction sites for immediate dental implant placement: technical Note. Int J Oral Maxillofac Implants 2013;28:911-916.
- Al-Shabeeb MS, Al-Askar M, Al-Rasheed A, Babay N, Javed F, Wang HL, Al-Hezaimi K. Alveolar Bone remodeling around immediate implants placed in accordance with the extraction socket classification: A three-dimensional microcomputed tomography analysis. J Periodontol 2012;83:981-987.