Socket management requires a strict evaluation of biological and aesthetic risk factors. The characteristics of the buccal bone determine the necessary procedure. This could be an immediate implantation with the insertion of implants at the time of tooth extraction. Early implantation is performed after minimally invasive tooth extraction and a healing time of 4–8 weeks, mostly following natural healing or socket seal technique. Delayed or late implantation in combination with socket preservation using bone substitute materials is a good option, particularly for thin buccal bone types. In cases of a non-intact buccal bone, ridge augmentation or preservation have to be carried out.
Immediate implant placement
The term immediate implant placement refers to a situation when a dental implant is placed at the same time as the tooth is extracted. The use of this approach offers the advantage of a reduced number of surgical interventions and reduced treatment time. Filling the gap around the inserted implant with a bone grafting material can improve implant stability and prevent resorption of the buccal wall.
Early implantation – Natural healing and socket seal technique
In an early implantation approach, the implant is placed within 4–8 weeks after tooth extraction. In this period, the soft tissue healing is complete and potential inflammations have been overcome, but bony regeneration has not taken place yet. Socket sealing using a soft tissue graft or soft tissue substitute (e.g., mucoderm®) facilitates the closure of the soft tissue/socket in this period.
Upon tooth extraction, the alveolar socket fills with blood. The formed blood coagulum is the starting point of the healing and regeneration of the socket. Thus, the formation of a stable coagulum is of great importance. The stabilization can be achieved by the application of a collagen sponge such as collacone®. Moreover, this sponge promotes the adhesion of thrombocytes, fibroblasts, and osteoblasts.
The socket seal technique aims to protect the socket cavity and prevent a soft tissue collapse and shrinkage of the attached gingiva after extraction and before implantation. Following extraction, the socket may be sealed with either a soft tissue transplant or a collagen matrix such as mucoderm®, which should be sutured to the gingival margins of the socket. Alternatively, a non-resorbable membrane such as permamem® can be used to cover the socket. The transplant or membrane supports the stabilization of the blood clot and protects it from bacterial contamination and physical damage. Besides, displacement of the mucogingival line is omitted. It is also possible to fill the socket with a bone grafting material prior to sealing. However, depending on the grafting material used, this will delay the timepoint of implantation
The alveolar socket is lined with bundle bone, which is supplied with nutrients by the periodontium and therefore resorbs after tooth extraction. In the case of a thin buccal bone type, the whole buccal wall may resorb. To maintain the volume of the alveoli, bone grafting material can be applied. Thus, enabling a stable implant placement later and improving the aesthetic outcome of the final prosthesis. As the implantation is scheduled within 10–16 weeks following extraction in a delayed implantation approach, allogeneic material such as maxgraft® granules are the best choice due to the fast osseous regeneration and complete remodeling potential. If the bony walls are intact the application of a barrier membrane is not necessarily needed. However, membranes (e.g., Jason® membrane, collprotec® membrane, permamem®) and fleece (Jason® fleece) are frequently used to prevent the migration of bone graft particles.
The late implantation approach has the same underlying biological background as the delayed implantation approach. When performing a late implantation, the use of a slow resorbable grafting material such as cerabone® is recommended to obtain a long-term stability of the socket volume. This is of particular importance, if the point of implantation is unknown or if a conventional restoration is planned later than 16 weeks after tooth extraction. cerabone® can also be applied with maxgraft® granules to combine the advantages of both materials. Alternatively, the synthetic material maxresorb® can be applied. When long-term stability is not necessarily needed a valid and easy-to-handle alternative is the use of bone-paste (maxresorb® inject) and composite material in a cone shape (collacone® max).