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Continuing Dental Education

IMPLANT DENTISTRY

Socket Preservation
for the General
Practitioner
Terry L. Work, DMD
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Socket Preservation
for the General Practitioner
Terr y L. Work, DMD
ABSTRACT
There are numerous benefits to
incorporating socket preservation into
a general dental practice. This article
describes the different materials nec-
essary for the procedure and shows
step-by-step photographs of the pro-
cess. It discusses proper case selec-
tion and treatment recommendations,
describes classes of bony defects, and
outlines postoperative follow-up. It also
explains the importance of atraumatic
tooth removal and defines the stages
of socket healing. In addition, the
article includes a discussion of the
different grafting materials used,
including their pros and cons, as well
as the various types of membranes
and their uses. Incorporation of socket
grafting into a general dental practice
is also discussed, outlining advantages
for both patient and practitioner.
LEARNING OBJECTIVES
• Identify cases that are
good candidates for socket
preservation.
• Discuss the importance of
atraumatic tooth extractions.
• Delineate the materials that
can be used to perform
socket preservation.
• Explain how to implement
socket preservation into a
general dental practice.
VOLUME 3 • NUMBER 54
PEER-REVIEWED
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F
or general practitioners, socket preservation can be an
excellent initial step to building an implant practice. Most
dentists extract teeth, though not all dentists want to place
implants. However, if socket preservation is performed, the area
is more likely to be suitable for an implant without grafting. As
Dr. Carl E. Misch has noted, taking something out should be
followed by putting something back in. Socket preservation,
however, is not just for patients who may have dental implants
placed.1 For some patients who are not candidates for dental
implants, there is value in maintaining bone volume for other
prostheses and for maintenance of bone around adjacent teeth.2
When performing a socket preservation on a patient, the clinician
should be prepared to place an implant in the area in 4 to 6 months.
Providing this service for patients will help grow the practice and
expand the clinician’s abilities. Offering these services in the dental
office must be done in a manner that is organized and properly
executed. The patient’s well-being is the most important factor.
Expanding the practice into the arena of implant placement should
be done methodically and carefully. Implant education along with
receiving mentoring is vital,3 as it enables an exchange of informa-
tion specific to a patient prior to the procedure.
There are a number of reasons for performing socket preserva-
tion. A study done by Iasella, Greenwell, et al4 found that grafting
of extraction sites with freeze-dried bone increased the height and
width of the alveolar ridge compared to sockets that were not grafted.
This maintenance of the ridge can be the difference between implant
success and failure. There are instances in which grafting distal to
second molars after third molar removal may be indicated. These are
patients aged 26 or older who have a risk of having a distal defect on
the second molar after removal of their wisdom teeth.5
CASE SELECTION
For clinicians who are inexperienced in socket preservation,
case selection is crucial in building experience. In some cases
CDEWORLD.COM 3
 1 2
Fig 1. Not a good candidate for socket preservation. Fig 2. Good candidate for socket preservation.
grafting may only exacerbate the situation. For
example, if the tissue is severly inflamed and
fragile (Figure 1), the healing will be less than
desireable and grafting may aggravate the area.
In such instances, after removal of the tooth,
wound management techniques (eg, antibiotics,
chlorhexidine, pain management) should be
used. Conversely, a good candidate for socket
preservation is one that is free from serious in-
fection (Figure 2).
For the inexperienced grafting clinician it is
best to start with a five-walled defect.6 There
are different treatment techniques used for the
different bony defects, as follows:
• Five-walled defect (extraction site with all its
walls intact): resorbable grafting material and
primary closure (or coverage with membrane)
• Four-walled defect: resorbable grafting mate-
rial and a membrane
• Three-walled defect: resorbable grafting
material, membrane, and growth factors or
4 CDEWORLD.COM
autogenous bone
• Two-walled defect: resorbable grafting material,
membrane, growth factors, autogenous bone,
and possibly titanium mesh for support
• One-walled defect: block graft
Starting with the least complex type of graft
allows the clinician to build experience and follow
routine healing protocols. As clinicians build confi-
dence they can gradually move into more compli-
cated procedures for their patients. Multiple tooth
extractions, for example, increase the complexity.
EXTRACTION SITE
Proper socket preservation starts with proper
tooth removal. The cells on the inner surface of
the periosteum are responsible for bone remodel-
ing. If these cells are damaged they have to regen-
erate before the bone can remodel. Cortical bone
receives 80% of its arterial and 100% of venous
blood flow from the periostium.7 Therefore, care-
ful handling of the soft tissue is crucial in succes-
ful socket preservation and grafting, in general.
OCTOBER 2016
 3 4
Fig 3. A nonrestorable molar.
5 that the epithelium crosses. The graft also helps
Fig 5. Atraumatic tooth removal.
Flap reflection should only be performed when
necessary and kept to a minimum. For multi-
rooted teeth careful sectioning will ensure the
soft tissues are protected. Periotomes can also be
used to sever the ligaments retaining the tooth to
aid in atraumatic removal.
Mandibular molars can be sectioned bucco-
lingually and each root removed individually.
Maxillary molars are sectioned mesio-distally
first, then the palatal root is removed bucco-
lingually, and the buccal roots removed individu-
ally (Figure 3 through Figure 5). If clinicians are
using an air-driven high-speed handpiece, they
should not lay a flap as this may give the patient
an air embolism.8 If a flap has been reflected,
an electric handpiece must be used.
VOLUME 3 • NUMBER 54
Fig 4. Careful sectioning has been performed.
Extraction site healing occurs in four stages9:
(1) initial angiogenesis–1 to 4 days; (2) new bone
formation–3 to 4 weeks; (3) bone growth–4 to
6 weeks; (4) bone reorganization–6 weeks to
4 months. Healing of an extraction site with-
out grafting occurs by the epithelium growing
into the extraction site until it reaches the api-
cal fibrous tissue. The epithelium grows across
the fibrous tissue until it meets in the middle.10
Socket preservation raises the level of the area
maintain the width of the ridge by minimizing
the remodeling of the buccal and lingual plates.11
GRAFTING TECHNIQUE
The patient’s own tissue, whether bone or soft
tissue, is considered the ideal grafting material.
Each of the four different types of bone grafting
material has its own “pros” and “cons”12:
• Autogenous: patient’s own bone. This is the
optimal graft for healing and integration;
however, its use requires another surgical
site and there could be limitations regarding
available amount.
• Allograft: harvested from the same species.
With allograft, there is no limit to available
amount. It has some osteoinductive proper-
ties, but patients may object to its use.
• Zenograft: harvested from a different species
CDEWORLD.COM 5
 6 7

8 9
Fig 6. Tooth has been sectioned. Fig 7. Periodontal ligament loosened. Fig 8. Socket cleaned of all debris.
Fig 9. Blood collected to mix with graft.

(eg, bovine). It has no limit to its availability,
however patients may object to using it. There
are some issues with resorption in that the
material may not fully resorb, and also it has
no inductive properties.
• Alloplast: synthetic material. While there is
no limit to availability and it resorbs nicely, is
very consistent, and has good handling prop-
erties, alloplast offers no inductive properties.
A mixture of different materials can be used
to try to utilize the best characteristics of each.
For example, the oseoinductive properties of de-
mineralized human bone may be desired along
with the handling properties of a synthetic.
(Oseoinduction is defined as new bone forma-
tion from osteoprogenitor cells derived from
primitive mesenchymal cells.13 Oseoconduction
creates a scaffolding for the surrounding bone
to form new bone.14)
Other techniques for improving the healing
of grafting sites can also be used. The patient’s
blood can be centrofuged to separate the differ-
ent components of it. These components have
growth factors that help in the healing process.
Platelet-rich plasma (PRP)15 and platelet-rich
fibrinogen (PRF) are collectively referred to
as platelet-derived growth factors,16 and when
mixed with grafting material they improve the
acceptance of the grafting materials.17 Many
dental offices are not interested in dealing with
this level of blood product handling; however,
if more advanced grafting is to be done, use of
these techniques will improve outcomes.17
MEMBRANE PLACEMENT
It is difficult to achieve primary closure of an
extraction site without tension on the tissue.
Therefore, a membrane frequently must be used
to keep the grafting material stable so the heal-
ing process can occur. There are two categories
of membranes: resorbable and nonresorbable.
This is also true for sutures. The author prefers

6 CDEWORLD.COM OCTOBER 2016

10 11

12 13

14 15
Fig 10. Membrane placed. Fig 11. Graft material deposited. Fig 12. Graft material gently condensed. Fig 13. Membrane tucked under
periosteum. Fig 14. Site secured with suture. Fig 15. Radiograph showing radiopacity of material.

polytetrafluoroethylene membranes and sutures
because of their non-inflammatory nature. The
healing around this material is excellent. Resorbable
membranes should only be used if primary closure
can be achieved. The nature of the oral environ-
ment will cause resorbable membranes to disolve
too quickly to allow proper healing.
The membrane should be placed under the
periosteum and over the bone so as to create
a 2-mm overlap.18 A horizontal matress suture
can be used to secure the tissue over the mem-
brane. Medications after the procedure include
amoxicillin 500 mg four times a day for 5 days
(if penicillin allergy, Cleocin 300 mg twice daily
for 5 days), Toradol 30 mg IM then 10 mg TQ6h
(ensuring patient has no aspirin allergies and is
not taking blood thinners),19 and chlorhexidine
gluconate rinse three times per day.
The case presented in Figure 6 through Figure
15 demonstrates membrane use in what would

VOLUME 3 • NUMBER 54 CDEWORLD.COM 7

 16
Fig 16. Two weeks after extraction.
18
Fig 18. Healing at 2 months.
be considered a four-wall defect. In such a case,
the patient would come to the office weekly
for evaluation of healing. The sutures would
be removed after 3 weeks and the membrane
after 4 weeks. The longer the membrane is left
in, the better the result. If there is any excudate
the membrane should be removed immediately.
There is no need for anesthetic before mem-
brane removal. The initial angiogenic stage
lasts for approximately 3 weeks, therefore it
is important to keep the area stable for that
amount of time.20
As demonstrated in Figure 16 through Figure
18, after removal of the membrane the area
should be free from inflammation and infection.
As shown, the area has ample attached gingiva
and adequate ridge width for implant placement.
8 CDEWORLD.COM
17
Fig 17. Immediately after membrane removal.
PROCEDURE IMPLEMENTATION
Patients can be informed that this procedure
is in the best interest of their long-term dental
health and that newer information has brought
to light the value in preserving the bone in the
extraction site and the surrounding teeth. While
some offices may be concerned about how to add
this procedure to their treatment planning, the
value of it can be seen once these patients begin
returning for follow-up treatment. While not
every patient will choose to have the procedure
done, consistent recommendations are likely
to improve the acceptance rate. The continued
follow-up will keep the office connected to the
patient and increase the probability that the pa-
tient will follow through with the remainder of
the treatment plan. A cost analysis should be
done to help the practice set a fair fee for the
procedure. Material costs and the cost of added
time and more follow-up appointments must be
determined. The procedure is billed as an extrac-
tion, bone graft, and separate membrane.
There may be many reasons dental offices do
not offer socket preservation procedures. Whether
it is lack of knowledge about the procedure or
assumptions that patients won’t accept the treat-
ment, it is important that the staff is educated
about the benefits of socket preservation. The staff
should understand the “vision” of the office in
order to support the clinician in his or her quest to
OCTOBER 2016
provide quality care while enhancing the capabili-
ties of the practice and increasing revenue. If all
members of the staff are in unison, patients are
more likely to respond positively.21
Whether clinicians are trying to build their
practice by placing implants or provide their
specialists with the optimum starting point,
learning socket preservation can be beneficial.
Patients’ expectations for complete dental care
are increasing; this includes minimizing their
time at the dental office. Offering socket pres-
ervation will save patients time and money in
the long run.
REFERENCES
1. Irinakis T, Tabesh M. Preserving the socket dimensions
with bone grafting in single sites: an esthetic surgical approach
when planning delayed implant placement. J Oral Implantol.
2007;33(3):156-163.
2. Child PL Jr, Christensen GJ. Extract and graft or extract
and dismiss? Dentaltown. September 2011:28-34.
3. Lopez N, Johnson S, Black N. Does peer mentoring work?
Dental students assess its benefits as an adaptive coping strat-
egy. J Dent Educ. 2010;74(11):1197-1205.
4. Iasella JM, Greenwell H, Miller RL, et al. Ridge preserva-
tion with freeze-dried bone allograft and a collagen membrane
compared to extraction alone for implant site development:
a clinical and histologic study in humans. J Periodontol.
2003;74(7):990-999.
5. Kugelberg CF. Periodontal healing two and four years after
impacted lower third molar surgery. A comparative retrospec-
tive study. Int J Oral Maxillofac Surg. 1990;19(6):341-345.
6. Misch CE. Contemporary Implant Dentistry. 3rd ed. St.
Louis, MO: Mosby Elsevier; 2008:876-878.
7. Roberts WE, Turley PK, Brezniak N, Fielder PJ. Implants:
Bone physiology and metabolism. CDA J. 1987;15(10):54-61.
8. Davies JM, Campbell LA. Fatal air embolism during dental
implant surgery: a report of three cases. Can J Anaesth.
1990;37(1):112-121.
9. Ohta Y. Comparative changes in microvasculature and
VOLUME 3 • NUMBER 54
bone during healing of implant and extraction sites. J Oral
Implantol. 1993;19(3):184-198.
10. Amler MH, Johnson PL, Salman I. Histological and
histochemical investigation of human alveolar socket heal-
ing in undisturbed extraction wounds. J Am Dent Assoc.
1960;61(7):32-44.
11. Van der Weijden F, Dell’Acqua F, Slot DE. Alveolar
bone dimensional changes of post-extraction sockets
in humans: a systematic review. J Clin Periodontol.
2009;36(12):1048-1058.
12. Misch CE. Contemporary Implant Dentistry. 3rd ed.
St. Louis, MO: Mosby Elsevier; 2008:857-861.
13. Urist MR, Strates BS. Bone morphogenetic protein. J
Dent Res. 1971;50(6):1392-1406.
14. Misch CE. Contemporary Implant Dentistry. 3rd ed.
St. Louis, MO: Mosby Elsevier; 2008:860-863.
15. Sunitha Raja V, Munirathnam Naidu E. Platelet-rich
fibrin: evolution of a second-generation platelet concentrate.
Indian J Dent Res. 2008;19(1):42-46.
16. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fi-
brin (PRF): a second-generation platelet concentrate. Part I:
technological concepts and evolution. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 2006;101(3):e37-e44.
17. Sequeria1 JP, Johri S. Platelet rich plasma: clinical ap-
plications in dentistry. Sch J Dent Sci. 2015;2(6):355-362.
18. Dimitriou R, Jones E, McGonagle D, Giannoudis PV.
Bone regeneration: current concepts and future directions.
BMC Med. 2011;9:66.
19. Fricke J, Halladay SC, Bynum L, Francisco CA. Pain
relief after dental impaction surgery using ketorolac, hy-
drocodone plus acetaminophen, or placebo. Clin Ther.
1993;15(3):500-509.
20. Ohta Y. Comparative changes in microvasculature and
bone during healing of implant and extraction sites. J Oral
Implantol. 1993;19(3):184-198.
21. Morreale SP, Osborn MM, Pearson JC. Why commu-
nication is important: A rationale for the centrality of the
study of communication. Journal of the Association for
Communication Administration. 2000;29:1-25.
CDEWORLD.COM 9
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Socket Preservation for the General Practitioner

Terry L. Work, DMD

1.  A study found that grafting of extraction sites with 6. Oseoinduction is defined as:
what increased the height and width of the alveolar A. production of bone around a grafting material,
ridge compared to sockets that were not grafted? which acts as a scaffolding.
A. bovine bone. B. the inflow of vascularity associated with arteriole
B. freeze-dried bone. growth as an extraction site heals.
C. fibrous tissue. C. new bone formation from osteoprogenitor cells
D. titanium mesh. derived from primitive mesenchymal cells.
D. bone chondrocytes that allow progenitor cells to
2. For the inexperienced grafting clinician it is best to proliferate around a vascular foci.
start with a:
A. two-walled defect. 7. Platelet-rich plasma (PRP) and platelet-rich fibrinogen
B. three-walled defect. (PRF) are collectively referred to as:
C. four-walled defect. A. a platelet-rich factory.
D. five-walled defect. B. probable respiratory failure.
3. Cortical bone receives what percent of its arterial C. periradicular fibrosis.
blood flow from the periosteum? D. platelet-derived growth factors.
A. 10% 8. Resorbable membranes should only be used:
B. 40% A. when the patient is allergic to penicillin.
C. 80% B. when the patient is taking blood thinners.
D. 100% C. if primary closure cannot be achieved.
D. if primary closure can be achieved.
4. Extraction site healing occurs in how many stages?
A. Four stages 9. In the four-wall defect case example presented,
B. Seven stages how often should the patient come in for evaluation
C. Nine stages of healing?
D. 10 stages A. Daily B. Weekly
C. Monthly D. Quarterly
5. Which of the following is considered the ideal
grafting material? 10. The initial angiogenic stage lasts for approximately:
A. Autogenous A. 3 weeks.
B. Allograft B. 4 weeks.
C. Zenograft C. 5 weeks.
D. Alloplast D. 6 weeks.

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