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2021
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ORIGINAL ARTICLE

Abdelsalam Elaskary, Moataz Meabed, Iman Abd-ElWahab Radi

Vestibular socket therapy with immediate implant

placement for managing compromised fresh
extraction sockets: A prospective single-arm clinical
study

KEY WORDS
aesthetics, bone graft, extraction socket, guided bone regeneration, immediate placement,
vestibular socket therapy

ABSTRACT
Purpose: To assess hard and soft tissues regenerated around immediate implants placed in com-
promised fresh extraction sockets using vestibular socket therapy 2 years postoperatively.
Materials and methods: Twenty-seven compromised fresh extraction sockets were managed
using vestibular socket therapy and immediate implant placement. After immediate implant
placement, a cortical bone shield was stabilised through a vestibular incision. The socket defect
was filled with particulate bone graft. Labial plate thickness and bone height were evaluated
1 and 2 years postoperatively using CBCT. The pink aesthetic score and probing depth were
recorded after 6 months, 1 year and 2 years. A Friedman test was used to study changes in the
reported outcomes over time, with the level of statistical significance set at P ≤ 0.05.
Results: All implants recorded a 100.0% survival rate. A statistically significant increase in bone
height (0.93 mm, P = 0.004) and apical (0.12 mm, P = 0.026), midfacial (1.26 mm, P < 0.001)
and crestal (0.86 mm, P < 0.001) bone thickness was observed after 2 years. The changes in pink
aesthetic score and probing depth were not significant: the pink aesthetic score was 12.48 ± 1.45
and the mean PD was 2.37 ± 0.79 mm mesially, 2.11 ± 0.70 mm facially, 2.07 ± 1.04 mm dis-
tally and 1.00 ± 0.00 mm palatally after 2 years.
Conclusion: Combining immediate implant placement with vestibular socket therapy to manage
compromised fresh extraction sockets offers promising radiographic, aesthetic and periodontal
results while minimising the treatment time and number of surgical procedures required.

Conflict-of-interest statement: None of the authors have any commercial relationships to

declare. The present research was totally self-funded.

Introduction where the labial plate bone and/or its overlying

Immediate implant placement is deemed the most
favourable and predictable therapy for replacing
unrestorable teeth in the aesthetic zone1-3. Unfor-
tunately, this treatment option does not appear
to be suitable in compromised extraction sockets,
soft tissues are deficient4. Two studies found that
the mean facial bone thickness was < 1.0 mm in
the majority of cases examined, particularly in the
central and lateral incisor sites, and ≤ 0.5 mm in
50% of sites5-6. Removal of a maxillary anterior
tooth leads to significant loss of its labial bone

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Elaskary et al Vestibular socket therapy in compromised sockets
profile within a few weeks7. As such, before the
prosthodontist decides to undertake implant place-
ment, it is mandatory to preserve the established
deficient bone and soft tissues3,8-12; however,
authors differ in opinion as to whether implants
should be placed immediately or whether place-
ment should be delayed until the bone graft has
healed. To avoid poor long-term aesthetic results,
some authors precluded immediate implant place-
ment in defective extraction sites10,13. A system-
atic review by Cosyn et al14 found that the gingival
phenotype and the degree of damage to the facial
bone plate were the major risk factors jeopardis-
ing aesthetics and promoting gingival recession.
Thus, some authors have recommended delaying
implant placement until the hard and soft tissue
thickness have been increased9,10. Buser et al13
advocated implant placement 4 to 8 weeks after
extraction and provided additional keratinised
tissue at the future implant site. Although this
technique demonstrated satisfactory functional
and aesthetic outcomes, it required a long treat-
ment time and multiple surgical interventions that
involved flap elevation, thereby increasing the
risk of gingival recession and loss of the recon-
structed alveolar ridge8,13,15. Furthermore, Hosny
and Radi16 expressed doubts about the evidence
that ridge preservation techniques, regardless of
the materials used, minimise the overall changes
in residual ridge height and width 6 months after
extraction.
As a result of the increased focus on aesthet-
ics, immediate implant placement has become
the treatment option of choice even in defective
sockets, especially when replacing anterior teeth.
Simultaneous socket enhancement and implant
placement in defective sockets was thus intro-
duced, using a tuberosity bone graft shaped to
match the labial plate and covered by a connect-
ive tissue graft, and a mixture of autogenous
and xenogeneic bone was used to fill the socket
gap17,18. The results were not inferior to those
achieved with a delayed implant placement proto-
col16; however, this approach required autogen-
ous bone grafts, which necessitated longer sur-
gical time and multiple incisions and increased the
risk of morbidity in the donor site19,20. Collagen
308
membranes placed inside the socket and combined
with allogeneic bone were used to overcome the
problems posed by the delayed implant placement
protocol and provided promising short-term results
for labial plate thickness21. Assaf et al22 placed
collagen-enriched bovine-derived xenogeneic
bone block in a mucoperiosteal pouch dissected to
extend 3.00 mm apical to the dehiscence defect
and reported a mean increase in labial bone plate
thickness of 2.38 mm. Elaskary et al23 introduced a
novel technique, namely vestibular socket therapy
(VST), whereby immediate implants were placed in
compromised fresh extraction sockets, a vestibular
access incision was made and a cortical bone shield
was stabilised. The defective socket was filled with
particulate bone graft, which was sealed using a
customised healing abutment23. The technique
showed promising results over a 6-month period
regarding soft and hard tissue outcomes23; how-
ever, a longer follow-up period was required. As
such, the present 2-year time series was conducted
to explore the changes in bone height, bone thick-
ness, probing depth and pink aesthetic score (PES),
and to investigate the effect of implant site and
soft tissue grafting on these outcomes when using
VST and immediate implant placement to restore
fresh extraction sockets.
Materials and methods
The present single-arm clinical study was reported
in accordance with the Transparent Reporting of
Evaluations with Nonrandomized Designs (TREND)
guidelines24. It was approved by the ethical com-
mittee at the Faculty of Dentistry, Cairo Univer-
sity (REC18.4.20) and conducted in accordance
with the Helsinki Declaration of 1975, as revised
in 2013. The study protocol was published on clin-
icaltrials.gov (NCT04332185).
A total of 20 adult patients aged ≥ 18 years
were recruited from January to November 2018
from a private clinical practice in Alexandria, Egypt,
where the intervention and outcome assessment
took place. The participants were included in the
study consecutively if they adhered to the follow-
ing inclusion criteria:
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Elaskary et al
Fig 1 Vestibular access incision con-
nected to the socket orifice via a sub-
periosteal tunnel.
• one to three non-adjacent hopeless maxillary
anterior teeth with type I and/or II sockets;
• labial bone plate deficient in width (type  I
sockets) and/or height (type II sockets) and
with the overlying soft tissues intact25.
Adequate palatal bone and at least 3.0 mm apical
bone needed to be available to engage the imme-
diately placed implants and thus achieve optimum
primary stability (30 Ncm insertion torque) follow-
ing tooth extraction.
The exclusion criteria were as follows:
• smoking;
• pregnancy;
• systemic disease;
• infected sockets;
• chemotherapy or radiotherapy within the pre-
vious 2 years.
Eligible patients were informed about the nature
of the study and signed an informed consent
to participate. Preoperative CBCT scans were
taken for all patients to ensure the fulfilment of
the abovementioned criteria and to assist with
treatment planning for the future implant pos-
ition and the construction of a computer-gener-
ated surgical guide. If patients were considered
eligible, they were given infiltration anaesthesia
(Artinibsa 4% 1:100,000, Inibsa Dental, Barce-
lona, Spain). The surgical procedure began with
atraumatic extraction of the compromised tooth
and mechanical and chemical debridement of the
sockets using metronidazole irrigation solution
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Vestibular socket therapy in compromised sockets
Fig 2 Bone shield stabilised to the apical bone using mem-
brane tacks.
(500 mg/100 ml, Amrizole, Amria Pharma, Alex-
andria, Egypt). VST was then used to manage
the defects. A 1-cm-long vestibular access incision
was cut using a 15c blade (Stoma/Storz am Mark,
Emmingen-Liptingen, Germany) 3.0 to 4.0 mm
apical to the mucogingival junction of the rele-
vant tooth. A  periotome and a microperiosteal
elevator (Stoma/Storz am Mark) were used to cre-
ate a subperiosteal tunnel connecting the socket
orifice and the vestibular access incision (Fig 1).
Implants (15.0 × 3.8 mm Tapered Pro, Laser-
Lok collar with resorbable blast texturing [RBT]
body, BioHorizons, Birmingham, AL, USA) were
placed using fully guided surgery. A CAD/CAM
surgical guide was manufactured using a 3D
stereolithography (SLA) printer (Form  2, Form-
labs, Somerville, MA, USA) and used for the pro-
cedure. This ensured the implants were placed
in the pre-planned positions while engaging 3.0
to 4.0 mm apical bone. A 0.6-mm-thick flexible
cortical membrane shield (OsteoBiol Lamina,
Tecnoss, Turin, Italy) of heterologous origin was
hydrated, trimmed and tacked through the ves-
tibular access incision until it extended 1.0 mm
below the socket orifice. It was then stabilised to
the apical bone using membrane tacks (AutoTac
System Kit, BioHorizons) (Fig 2). The gap between
the implant and the shield/labial plate was then
filled with particulate bone graft (75% autogen-
ous bone chips harvested from local surgical sites
and 25% deproteinised bovine bone mineral
[DBBM] of equine origin, fully enzyme deanti-
genised [Bio-Gen Mix, Bioteck, Vicenza, Italy]).
309
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Elaskary et al Vestibular socket therapy in compromised sockets
Fig 3 Connective tissue grafting of sockets with a thin gin-
gival phenotype.
a b
Figs 5a-b Soft tissues around the left central incisor (a) 2 months and (b) 2 years after implant placement.
For patients with a thin gingival phenotype,
determined based on probe transparency as
recommended by De Rouck et al26, soft tissue
grafting was performed using a subepithelial
connective tissue graft harvested from the palate
using a single incision technique (Fig 3)27. The
graft was secured to the inner surface of the soft
tissue tunnel using 6-0 nylon sutures (Stoma/
Storz am Mark). Finally, the vestibular incision
was secured using the same suture material. A
customised healing abutment was used to create
a sealed chamber that preserved the bone graft
(Fig 4) using composite resin (Filtek Supreme
Ultra Flowable Restorative, 3M, St Paul, MN,
USA) and a temporary abutment (PEEK Tem-
porary Cylinder, BioHorizons). The sutures were
removed 10 days after surgery and final crowns
310
Fig 4 Customised healing abutment used to create a sealed
chamber that preserved the bone graft.
(BruxZir full anatomical zirconia, Glidewell,
Newport Beach, CA, USA) were cemented after
2 months (Fig 5). Patients were instructed to take
500 mg metronidazole and 500 mg ciprofloxacin
(Minapharm Pharmaceuticals, Cairo, Egypt)
every 12  hours the day before surgery and for
5 days after surgery and a non-steroidal anti-
inflammatory drug in the form of Catafast 50-mg
sachets (Novartis, Basel, Switzerland), to use
0.12% chlorhexidine mouthrinse three times
daily, to apply cold packs to the operative site
every 20  minutes for the first 2  hours, and to
adhere to strict oral hygiene measures. Follow-
up visits were scheduled for 6 months and 1 and
2 years after surgery to record the study out-
comes. All soft tissue outcomes were assessed
6 months (baseline for soft tissues) and 1 and
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a b

c d e

Figs 6a-e Bone height and thickness measurements taken after superimposing images of the different follow-up periods. (a) 3D view of the super-
imposed CBCTs; (b) superimposed images in a frontal cut section; (c) thickness and height measurements taken 2 years after implant placement;
(d) measurements taken on the fused sagittal cut section; (e) measurements taken after extraction and after concealing the implant.

2 years postsurgically, and the bone was assessed
prior to implant placement and after extraction
(baseline for bone assessment), 1 and 2 years
postsurgically. The outcomes were recorded by
two experienced independent examiners (MM
and AE) and the mean values were recorded for
bone height, bone thickness and probing depth.
Interexaminer agreement was 80%. Any dis-
agreement between the examiners regarding the
PES was resolved by a third examiner (IR). The
study outcomes were as follows:
• Implant success as described by Buser et al28:
Absence of peri-implant infection, persistent
subjective complaints such as pain, foreign
body sensation and/or dysesthesia, radio-
lucency around the implant and/or any detect-
able implant mobility.
• Thickness and height of labial bone plate: Images
obtained at baseline and at the 1- and 2-year
follow-ups were superimposed. Patients were
radiographed using a wax interocclusal record
to separate the maxillary and mandibular teeth
between 5 and 10 kVp. The field of vision was
6 × 8 mm and the CBCT machine (CS 8100 3D
System, Carestream Dental, Atlanta, GA) used for
imaging had a high contrast resolution detector
(high bit depth). These specifications decreased
the beam hardening effect. OnDemand 3D soft-
ware (Cybermed, Seoul, South Korea) was used.
Thickness measurements were taken at three
levels: at the crestal bone level, at half of the
implant length and at the implant apex. Bone
height was measured from the implant apex to
the labial bone plate crest (Fig 6).

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Table 1 Baseline characteristics of participants

Site Variable Soft tissue graft No soft tissue graft Irrespective of soft tissue graft P value
Central incisor Age (y), mean ± SD 41.00 ± 5.06 44.00 ± 10.79 41.43 ± 8.07 0.628
Sex (M/F) 5/2 1/5 6/7 0.103
BH (mm), mean ± SD 10.72 ± 2.17 11.64 ± 2.46 11.73 ± 3.21 0.534
BTA (mm), mean ± SD 3.25 ± 1.17 1.94 ± 0.63 2.99 ± 1.78 0.110
BTM (mm), mean ± SD 0.46 ± 0.32 0.58 ± 0.33 1.91 ± 0.73 0.929
BTC (mm), mean ± SD 0.32 ± 0.35 0.55 ± 0.46 0.46 ± 0.35 0.341
PDM (mm), mean ± SD 1.50 ± 0.55 2.33 ± 0.52 2.11 ± 0.68 0.029*
PDF (mm), mean ± SD 2.00 ± 0.00 2.17 ± 0.75 2.05 ± 0.54 0.611
PDD (mm), mean ± SD 2.00 ± 0.00 1.50 ± 0.55 1.88 ± 0.47 0.032*
PDP (mm), mean ± SD 1.00 ± 0.00 1.00 ± 0.00 1.00 ± 0.00 1.000
PES (range) 12.50 (11.00–14.00) 12.00 (11.00–14.00) 12.44 (11.00–14.00) 0.521
Lateral incisor Age (y), mean ± SD 37.00 ± 7.07 48.20 ± 8.90 41.00 ± 11.45 0.241
Sex (M/F) 2/0 2/3 4/3 0.429
BH (mm), mean ± SD 13.40 ± 0.57 9.87 ± 4.31 11.58 ± 3.68 0.558
BTA (mm), mean ± SD 3.50 ± 1.41 3.46 ± 1.00 3.01 ± 1.27 0.770
BTM (mm), mean ± SD 1.87 ± 0.00 0.38 ± 0.43 0.62 ± 0.07 0.031*
BTC (mm), mean ± SD 0.00 ± 0.00 1.10 ± 1.25 0.76 ± 1.00 0.126
PDM (mm), mean ± SD 3.00 ± 0.00 2.20 ± 1.10 2.22 ± 0.97 0.190
PDF (mm), mean ± SD 1.00 ± 0.00 2.40 ± 0.55 1.88 ± 0.78 0.060
PDD (mm), mean ± SD 2.00 ± 0.00 3.20 ± 1.64 2.44 ± 1.50 1.000
PDP (mm), mean ± SD 1.00 ± 0.00 1.00 ± 0.00 1.00 ± 0.00 1.000
PES (range) 13.00 (13–13) 13.00 (13–14) 13.44 (13–14) 0.176

*Significant at P ≤ 0.05.
BH, bone height; BTA, bone thickness apically; BTC, bone thickness crestally; BTM, bone thickness in middle region; F, female; M, male; PDD, probing
depth distally; PDF, probing depth facially; PDM, probing depth mesially; PDP, probing depth palatally.

• PES as described by Fürhauser et al29: The Statistical methods

score includes seven variables: mesial papilla,
distal papilla, soft tissue level, soft tissue con-
tour, alveolar process deficiency, soft tissue
colour and texture. Each variable is scored
from 0 to 2, with 0 being the lowest and 2
being the highest value, such that the total
PES score ranges from 0 to the highest pos-
sible overall score of 14.
• Probing depth: The peri-implant probing depth
was recorded mid-mesially, midfacially, mid-
distally and midpalatally using a periodontal
probe (graduated Williams periodontal probe,
Stoma/Storz am Mark).
The data were checked for normality using a Kol-
mogorov-Smirnov and Shapiro-Wilk test. They
were presented as mean, standard deviation (SD),
median and range. All outcomes showed a non-
parametric distribution. A Friedman test was used
to study the effect of time on the study outcomes,
followed by a Dunn test for pairwise comparisons.
A post hoc Mann-Whitney U test was used to
explore the effect of implant site and soft tissue
grafting as subgroups. For binary variables like sex,
a Fisher exact test was used to compare the base-
line characteristics between the groups. The level
of statistical significance was set at P ≤ 0.05. Stat-
istical analysis was performed using SPSS Statistics
(version 23.0, IBM, Armonk, NY, USA).

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Table 2 Results of Friedman test showing the effect of time on the study outcomes

Outcome Baseline 1 year 2 years P value Effect

size
Mean ± SD Median (range) Mean ± SD Median (range) Mean ± SD Median (range) (w)
BH (mm) 11.68 ± 3.31 12.45 (3.50–16.73)b 12.79 ± 1.63 13 (9.50–16.23)a 12.61 ± 1.60 12.88 (9.50–16.00)a 0.004* 0.206
BTA (mm) 3.00 ± 1.61 2.76 (0.44–7.76)b 3.18 ± 1.61 2.76 (1.24–7.76)a 3.12 ± 1.58a 2.76 (1.24–7.76) 0.026* 0.135
BTM (mm) 0.55 ± 0.57 0.44 (0.00–1.87)b 1.99 ± 0.92 1.73 (0.66–3.98)a 1.82 ± 0.90 1.52 (0.66–3.81)a < 0.001* 0.949
BTC (mm) 0.56 ± 0.64 0.54 (0.00–2.87)b 1.49 ± 0.69 1.52 (0.52–2.87)a 1.37 ± 0.68 1.40 (0.50–2.80)a < 0.001* 0.694
PDM (mm) 2.15 ± 0.77 2.00 (1.00–3.00) 2.37 ± 0.79 2.00 (1.00–4.00) 2.37 ± 0.79 2.00 (1.00–4.00) 0.368 0.037
PDF (mm) 2.00 ± 0.62 2.00 (1.00–3.00) 2.11 ± 0.70 2.00 (1.00–4.00) 2.11 ± 0.70 2.00 (1.00–4.00) 1.000 0.000
PDD (mm) 2.07 ± 0.96 2.00 (1.00–5.00) 2.07 ± 1.04 2.00 (1.00–5.00) 2.07 ± 1.04 2.00 (1.00–5.00) 0.819 0.007
PDP (mm) 1.00 ± 0.00 1.00 (1.00–1.00) 1.00 ± 0.00 1.00 (1.00–1.00) 1.00 ± 0.00 1.00 (1.00–1.00) NR NR
PES 12.78 ± 1.09 13.00 (11.00–14.00) 12.67 ± 1.27 13.00 (10.00–14.00) 12.48 ± 1.45 13.00 (9.00–14.00) 0.135 0.074

*Significantat P ≤ 0.05. Values with different superscript letters were statistically significant.
NR, not reported.

Results implant placement, favouring the lateral incisor

The present study was conducted on 20 sub-
jects, 10 men and 10 women, with a mean age
of 45.5 ± 9.4 years and an age range of 27 to
59 years. All participants attended the follow-up
visits. A total of 27 implants were investigated:
18 (66.7%) placed in the central incisor and 9
(33.3%) in the lateral incisor sites. Fifteen of the
implants studied (55.6%) had a thin gingival bio-
type and received labial soft tissue grafts. Twelve
patients had 14 implant sites with type II socket
defects, seven of which were in the central inci-
sor site. The unit of analysis was the implant,
and no data were missing. The baseline charac-
teristics of the included patients are presented
in Table 1.
All the implants placed recorded a 100.0%
survival and success rate. The results of the study
outcomes are shown in Tables 2 to 4. A signifi-
cant increase in bone height and thickness (all
regions) was observed after 1 year compared
to the preoperative radiographs; however, the
effect sizes remained relatively stable, with clin-
ically insignificant changes 2 years after implant
insertion when compared to the 1-year changes
(Table  2). Concerning implant site, a signifi-
cant difference in the PES was found between
the central and lateral incisor sites 2 years after
site (Table 3). Soft tissue grafting was found to
have a significant impact on bone thickness in
the midfacial region of the implant, favouring
the no graft group in the first year and the graft
group in the second; however, close observation
of the changes in both groups showed no clinical
significance (Table 4). The comparison between
type I and type II socket defects revealed signifi-
cant changes in bone height after 1 and 2 years
and in bone thickness apically after 1 and 2 years
and in the midfacial region of the implant after
2 years (Table 5). With regard to the effect of
time in type I and II sockets, no significant dif-
ference was found between the 1- and 2-year
follow-ups. Significant differences were only
recorded between baseline and the 1- and 2-year
follow-ups regarding bone height and bone thick-
ness crestally and in the midfacial region of the
implant for both type I and II sockets, and apically
for type II sockets only (Tables 6 and 7).
Discussion
Immediate implant placement is a challenging
treatment option for replacing failing teeth in
the aesthetic region, especially those with thin or
absent labial bone plate. The establishment and

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Table 3 Results of Mann-Whitney U test showing the effect of implant site on the study outcomes

Outcome Time period Central incisor site (n = 18 implants) Lateral incisor site (n = 9 implants) P value Effect size
(d)
Mean ± SD Median (range) Mean ± SD Median (range)
BH (mm) 0–1 y 0.92 ± 2.61 1.00 (−3.10–6.39) 1.49 ± 2.74 1.43 (−1.08–7.86) 0.817 0.089
1–2 y 0.74 ± 2.67 0.67 (−3.40–6.39) 1.30 ± 2.76 0.90 (−1.28–7.66) 0.758 0.119
1–2 y −0.17 ± 0.15 −0.16 (−0.50–0.00) −0.19 ± 0.19 −0.20 (−0.64–0.00) 0.697 0.149
BTA (mm) 0–1 y 0.10 ± 0.26 0.00 (0.00–1.02) 0.33 ± 1.00 0.00 (−1.00–2.00) 0.841 0.059
0–2 y 0.08 ± 0.25 0.00 (−0.09–1.02) 0.20 ± 0.80 0.00 (−1.10–1.50) 0.702 0.119
1–2 y −0.02 ± 0.04 0.00 (0.00–0.00) −0.13 ± 0.23 0.00 (−0.57–0.00) 0.366 0.270
BTM (mm) 0–1 y 1.40 ± 0.57 1.32 (0.28–2.55) 1.51 ± 0.89 1.51 (0.29–2.63) 0.699 0.149
0–2 y 1.24 ± 0.57 1.28 (0.18–2.55) 1.33 ± 0.96 1.41 (0.29–2.60) 0.837 0.079
1–2 y −0.16 ± 0.22 −0.10 (−0.82–0.00) −0.17 ± 0.32 −0.08 (−1.00–0.00) 0.603 0.199
BTC (mm) 0–1 y 1.03 ± 0.61 1.07 (0.04–2.18) 0.72 ± 1.44 1.00 (−2.35–2.25) 0.837 0.079
0–2 y 0.90 ± 0.56 0.97 (−0.03–2.11) 0.64 ± 1.44 0.87 (−2.35–2.15) 1.000 0.000
1–2 y −0.13 ± 0.15 −0.10 (−0.48–0.00) −0.08 ± 0.07 −0.10 (−0.20–0.00) 0.677 0.159
PDM (mm) 0–1 y 0.33 ± 0.69 0.00 (0.00–2.00) 0.00 ± 1.32 0.00 (−2.00–2.00) 0.243 0.383
0–2 y 0.33 ± 0.69 0.00 (0.00–2.00) 0.00 ± 1.32 0.00 (−2.00–2.00) 0.243 0.383
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDF (mm) 0–1 y 0.00 ± 0.59 0.00 (−1.00–2.00) 0.33 ± 1.00 0.00 (−1.00–2.00) 0.395 0.239
0–2 y 0.00 ± 0.59 0.00 (−1.00–2.00) 0.33 ± 1.00 0.00 (−1.00–2.00) 0.395 0.239
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDD (mm) 0–1 y 0.06 ± 0.64 0.00 (−1.00–2.00) −0.11 ± 0.33 0.00 (−1.00–0.00) 0.543 0.159
0–2 y 0.06 ± 0.64 0.00 (−1.00–2.00) −0.11 ± 0.33 0.00 (−1.00–0.00) 0.543 0.159
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PES 6 m–1 y 0.06 ± 0.87 0.00 (−2.00–2.00) −0.44 ± 0.88 0.00 (−2.00–0.00) 0.229 0.341
6 m–2 y 0.00 ± 1.03 0.00 (−3.00–2.00) −0.89 ± 1.17 0.00 (−3.00–0.00) 0.041* 0.668
1–2 y −0.06 ± 0.24 0.00 (−1.00–0.00) −0.44 ± 0.73 0.00 (−2.00–0.00) 0.055 0.468

*Significantat P ≤ 0.05.
NC, not computed (P value could not be computed since the values compared were the same).

preservation of the labial mucosa and under-
lying buccal bone are crucial to achieving optimal
aesthetic results. The combination of osseous re-
generation and soft tissue augmentation has been
claimed to prevent further bone loss and mucosal
recession, but the results are contradictory3,8,11.
The present 2-year study showed that VST could
represent a successful method for managing both
type I and II socket defects, and could shorten
the treatment time by up to two-thirds of that
required for bone grafting and delayed implant
placement. Immediate implant placement per se
could preserve some of the bone volume that
might be lost after tooth extraction due to the nat-
ural remodelling process15,30. The 100.0% survival
rate recorded by the technique in defective sockets
over a 2-year period, irrespective of the studied
region and the socket defect type, is promising
and could be attributed to several factors. The use
of a slowly resorbing flexible labial shield allowed
for remodelling of the underlying labial bone plate
while maintaining the socket dimensions and con-
tours throughout the follow-up period. This also
explains why there was no significant difference in
bone height and thickness in the studied regions
1 and 2 years after implant placement31. A mean

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Table 4 Results of Mann-Whitney U test for comparison of the effect of implants placed with and without soft tissue graft on changes in the study
outcomes

Outcome Time period No graft (n = 12 implants) Soft tissue graft (n = 15 implants) P value Effect size
(d)
Mean ± SD Median (range) Mean ± SD Median (range)
BH (mm) 0–1 y 1.31 ± 2.57 1.96 (−3.10–6.39) 0.95 ± 2.74 0.00 (−2.42–7.86) 0.494 0.265
0–2 y 1.12 ± 2.63 1.78 (−3.40–6.39) 0.77 ± 2.76 −0.20 (−2.45–7.66) 0.464 0.285
1–2 y −0.19 ± 0.15 −0.22 (−0.4–0.00) −0.18 ± 0.18 −0.16 (−0.64–0.00) 0.522 0.246
BTA (mm) 0–1 y 0.29 ± 0.62 0.00 (0.00–2.00) 0.09 ± 0.60 0.00 (−1.00–2.00) 0.173 0.412
0–2 y 0.22 ± 0.51 0.00 (−0.09–1.50) 0.04 ± 0.48 0.00 (−1.10–1.43) 0.809 0.075
1–2 y −0.07 ± 0.14 0.00 (−0.50–0.00) −0.05 ± 0.15 0.00 (−0.57–0.00) 0.526 0.189
BTM (mm) 0–1 y 1.70 ± 0.41 1.72 (1.05–2.23) 1.23 ± 0.79 1.13 (0.28–2.63) 0.045* 0.834
0–2 y 1.45 ± 0.48 1.46 (0.51–2.13) 1.13 ± 0.84 1.00 (0.18–2.60) 0.118 0.630
1–2 y −0.24 ± 0.23 −0.18 (−0.82–0.00) −0.10 ± 0.25 −0.03 (−1.00–0.00) 0.002* 1.504
BTC (mm) 0–1 y 1.01 ± 0.51 0.96 (0.20–2.18) 0.86 ± 1.21 1.11 (−2.35–2.25) 0.807 0.094
0–2 y 0.89 ± 0.49 0.85 (0.20–2.11) 0.75 ± 1.18 1.11 (−2.35–2.15) 0.660 0.170
1–2 y −0.12 ± 0.12 −0.1 (−0.40–0.00) −0.11 ± 0.13 −0.10 (−0.48–0.00) 0.882 0.056
PDM (mm) 0–1 y 0.08 ± 0.79 0.00 (−1.00–2.00) 0.33 ± 1.05 0.00 (−2.00–2.00) 0.382 0.285
0–2 y 0.08 ± 0.79 0.00 (−1.00–2.00) 0.33 ± 1.05 0.00 (−2.00–2.00) 0.382 0.285
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDF (mm) 0–1 y 0.25 ± 0.87 0.00 (−1.00–2.00) 0.00 ± 0.65 0.00 (−1.00–2.00) 0.420 0.227
0–2 y 0.25 ± 0.87 0.00 (−1.00–2.00) 0.00 ± 0.65 0.00 (−1.00–2.00) 0.420 0.227
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDD (mm) 0–1 y −0.08 ± 0.51 0.00 (−1.00–1.00) 0.07 ± 0.59 0.00 (−1.00–2.00) 0.589 0.141
0–2 y −0.08 ± 0.51 0.00 (−1.00–1.00) 0.07 ± 0.59 0.00 (−1.00–2.00) 0.589 0.141
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDP (mm) All time periods 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PES 6 m–1 y 0.00 ± 0.00 0.00 (0.00–0.00) −0.20 ± 1.21 0.00 (−2.00–2.00) 0.421 0.227
6 m–2 y −0.08 ± 0.29 0.00 (−1.00–0.00) −0.47 ± 1.51 0.00 (−3.00–2.00) 0.414 0.256
0–2 y −0.08 ± 0.29 0.00 (−1.00–0.00) −0.27 ± 0.59 0.00 (−2.00–0.00) 0.385 0.208

*Significantat P ≤ 0.05.
NC, not computed (P value could not be computed since the values compared were the same).

thickness of 3.12 mm apically, 1.80 mm midfa-
cially and 1.37 mm crestally was maintained by
the end of the follow-up period, despite starting
with a mean thickness of 0.55 mm midfacially and
0.56 mm crestally. The technique does not eliminate
bone resorption; 0.18 mm bone height and a max-
imum of 0.17 mm bone width were lost in the sec-
ond year. These measurements were standardised
using OnDemand 3D software that was employed
to superimpose the images captured at the differ-
ent study periods. The measuring technique was
proven to be reliable32. The present study recorded
more optimal results for bone height and thickness
than Buser et al13, Lee et al33 and Mazzocco et al34;
the former reported a 0.18-mm reduction in bone
height after 1 year, the second a 0.78-mm reduc-
tion after a period of 4 to 12 months and the lat-
ter a 0.5-mm reduction in bone height and width
after 6 months. Maintaining bone thickness and
contour was reported to be difficult when using
particulate bone grafts with or without collagen
membranes1-4. The latter tend to collapse due to
their fast biodegradation by the enzymatic activ-
ity of the macrophages and polymorphonuclear
leucocytes; this could explain their limited ability
to preserve bone contour, especially in sites with

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Table 5 Results of Mann-Whitney U test for comparison of the effect of type I and II socket defects on changes in the study outcomes

Outcome Time period Type I (n = 13 implants) Type II (n = 14 implants) P value Effect size
(d)
Mean ± SD Median (range) Mean ± SD Median (range)
BH (mm) 0–1 y −1.04 ± 1.03 −0.72 (−3.10–0.34) 3.11 ± 1.96 2.19 (1.43–7.86) < 0.001* 3.225
0–2 y −1.23 ± 1.02 −0.88 (−3.40–−0.10) 2.94 ± 2.04 1.98 (0.90–7.66) < 0.001* 3.225
1–2 y −0.19 ± 0.12 −0.17 (−0.50–−0.03) −0.17 ± 0.20 −0.15 (−0.64–0.00) 0.448 0.293
BTA (mm) 0–1 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.34 ± 0.82 0.00 (−1.00–2.00) 0.041* 0.637
0–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.23 ± 0.68 0.00 (−1.10–1.50) 0.435 0.245
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) −0.11 ± 0.19 −0.05 (−0.57–0.00) 0.004* 0.939
BTM (mm) 0–1 y 1.23 ± 0.80 1.13 (0.28–2.63) 1.63 ± 0.89 1.51 (0.75–2.51) 0.114 0.637
0–2 y 1.19 ± 0.81 1.11 (0.18–2.60) 1.35 ± 0.62 1.37 (0.29–2.51) 0.409 0.322
1–2 y −0.04 ± 0.04 −0.02 (−0.10–0.00) −0.28 ± 0.30 −0.18 (−1.00–0.00) 0.001* 1.644
BTC (mm) 0–1 y 0.57 ± 1.06 0.63 (−2.35–1.77) 1.26 ± 0.73 1.12 (−0.35–2.25) 0.109 0.648
0–2 y 0.50 ± 1.03 0.61 (−2.35–1.66) 1.10 ± 0.74 1 (−0.55–2.15) 0.159 0.563
1–2 y −0.07 ± 0.08 −0.05 (−0.29–0.00) −0.16 ± 0.15 −0.12 (−0.48–0.00) 0.055 0.782
PDM (mm) 0–1 y 0.46 ± 1.13 0.00 (−2.00–2.00) 0.00 ± 0.68 0.00 (−1.00–2.00) 0.105 0.542
0–2 y 0.46 ± 1.13 0.00 (−2.00–2.00) 0.00 ± 0.68 0.00 (−1.00–2.00) 0.105 0.542
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDF (mm) 0–1 y −0.08 ± 0.76 0.00 (−1.00–2.00) 0.29 ± 0.73 0.00 (0.00–2.00) 0.109 0.460
0–2 y −0.08 ± 0.76 0.00 (−1.00–2.00) 0.29 ± 0.73 0.00 (0.00–2.00) 0.109 0.460
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDD (mm) 0–1 y 0.16 ± 0.69 0.00 (−1.00–2.00) −0.14 ± 0.36 0.00 (−1.00–0.00) 0.197 0.341
0–2 y 0.15 ± 0.69 0.00 (−1.00–2.00) −0.14 ± 0.36 0.00 (−1.00–0.00) 0.197 0.341
1–2 y 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
PDP (mm) All time 0.00 ± 0.00 0.00 (0.00–0.00) 0.00 ± 0.00 0.00 (0.00–0.00) NC NC
periods
PES 6 m–1 y −0.23 ± 1.01 0.00 (−2.00–2.00) 0.00 ± 0.78 0.00 (−2.00–2.00) 0.404 0.235
6 m–2 y −0.46 ± 1.27 0.00 (−3.00–2.00) −0.14 ± 1.03 0.00 (−3.00–2.00) 0.417 0.254
1–2 y −0.23 ± 0.60 0.00 (−2.00–0.00) −0.14 ± 0.36 0.00 (−1.00–0.00) 0.875 0.037

*Significantat P ≤ 0.05.
NC, not computed (P value could not be computed since the values compared were the same).

Table 6 Results of Friedman test showing the effect of time on the study outcomes in type I sockets

Outcome Baseline (n = 13 implants) 1 year (n = 13 implants) 2 years (n = 13 implants) P value Effect

size (w)
Mean ± SD Median (range) Mean ± SD Median (range) Mean ± SD Median (range)
BH (mm) 13.75 ± 1.20 13.58 (12.21–16.73)a 12.71 ± 1.11 13.00 12.52 ± 1.10 12.88 < 0.001* 0.905
(10.49–13.96)b (10.20–13.80)b
BTA (mm) 2.82 ± 1.36 2.66 (1.24–5.07) 2.82 ± 1.36 2.66 (1.24–5.07) 2.82 ± 1.36 2.66 (1.24–5.07) NC NC
BTM (mm) 0.43 ± 0.37 0.44 (0.00–1.04)b 1.66 ± 0.74 1.48 (0.66–2.76)a 1.63 ± 0.75 1.40 (0.66–2.66)a < 0.001* 0.930
BTC (mm) 0.86 ± 0.63 0.68 (0.46–2.87)b 1.43 ± 0.78 1.52 (0.52–2.79)a 1.36 ± 0.74 1.50 (0.50–2.50)a < 0.001* 0.641
PDM (mm) 2.00 ± 0.71 2.00 (1.00–3.00) 2.46 ± 0.88 3.00 (1.00–4.00) 2.46 ± 0.88 3.00 (1.00–4.00) 0.069 0.205
PDF (mm) 2.08 ± 0.64 2.00 (1.00–3.00) 2.00 ± 0.82 2.00 (1.00–4.00) 2.00 ± 0.82 2.00 (1.00–4.00) 0.368 0.077
PDD (mm) 1.69 ± 0.63 2.00 (1.00–3.00) 1.85 ± 0.80 2.00 (1.00–3.00) 1.85 ± 0.80 2.00 (1.00–3.00) 0.717 0.026
PDP (mm) 1.00 ± 0.00 1.00 (1.00–1.00) 1.00 ± 0.00 1.00 (1.00–1.00) 1.00 ± 0.00 1.00 (1.00–1.00) NC NC
PES 12.69 ± 1.18 13.00 (11.00–14.00) 12.46 ± 1.51 13.00 12.23 ± 1.69 12.00 (9.00–14.00) 0.210 0.120
(10.00–14.00)

*Significant at P ≤ 0.05. Values with different superscript letters were statistically significant.

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Table 7 Results of Friedman test showing the effect of time on the study outcomes in type II sockets

Outcome Baseline (n = 14 implants) 1 year (n = 14 implants) 2 years (n = 14 implants) P value Effect

size (w)
Mean ± SD Median (range) Mean ± SD Median (range) Mean ± SD Median (range)

BH (mm) 9.76 ± 3.51 10.74 (3.50–14.57)b 12.87 ± 2.04 13.20 12.70 ± 2.00 12.72 < 0.001* 1.003
(9.50–16.23)a (9.50–16.00)a
BTA (mm) 3.17 ± 1.84b 3.04 (0.44–7.76) 3.51 ± 1.79a 3.41 (1.46–7.76) 3.40 ± 1.76a 3.36 (1.36–7.76) 0.026* 0.260
BTM (mm) 0.66 ± 0.71b 0.48 (0.00–1.87) 2.29 ± 0.98a 2.09 (1.26–3.98) 2.00 ± 1.01a 1.76 (0.73–3.81) < 0.001* 0.983
BTC (mm) 0.28 ± 0.54b 0.00 (0.00–1.87) 1.54 ± 0.63a 1.55 (0.53–2.87) 1.38 ± 0.64a 1.36 (0.53–2.80) < 0.001* 0.745
PDM (mm) 2.29 ± 0.83 2.50 (1.00–3.00) 2.29 ± 0.73 2.00 (1.00–3.00) 2.29 ± 0.73 2.00 (1.00–3.00) 0.717 0.024
PDF (mm) 1.93 ± 0.62 2.00 (1.00–3.00) 2.21 ± 0.58 2.00 (1.00–3.00) 2.21 ± 0.58 2.00 (1.00–4.00) 0.135 0.143
PDD (mm) 2.43 ± 1.09 2.00 (2.00–5.00) 2.29 ± 1.20 2.00 (1.00–5.00) 2.29 ± 1.20 2.00 (1.00–5.00) 0.135 0.143
PDP (mm) 1.00 ± 0.00 1.00 (1.00–1.00) 1.00 ± 0.00 1.00 (1.00–1.00) 1.00 ± 0.00 1.00 (1.00–1.00) NC NC
PES 12.86 ± 1.03 13.00 (11.00– 12.86 ± 1.03 13.00 12.71 ± 1.20 13.00 0.497 0.050
14.00) (11.00–14.00) (10.00–14.00)

*Significant at P ≤ 0.05. Values with different superscript letters were statistically significant.
NC, not computed (P value could not be computed since the values compared were the same).

high muscular and frenular activity such as the cen-
tral incisor site35. Furthermore, vertical releasing
incisions and full-thickness flap reflections, often
performed in grafted healed sockets augmented
with collagen membranes, are associated with
postoperative mucosal recession36. On the other
hand, the use of titanium mesh to preserve the
contour of the reconstructed defect could cause
complications due to secondary wound closure,
flap dehiscence and the need for a second surgical
procedure to remove the barrier31. Another factor
that contributed to the success of VST was the use
of particulate bone graft composed of a mixture
of deproteinised and autogenous bone harvested
from the local surgical site. This enhanced osteo-
inductivity has been found to boost bone regen-
eration and eliminate the need for a donor site,
thus decreasing the comorbidity of the latter and
reducing pain and annoyance to the patient20,37.
Furthermore, a vestibular access incision was made
to ensure stabilisation of the labial shield; this is
essential for successful bone regeneration38. This
was augmented by connective tissue grafting in
type II sockets exhibiting a thin biotype. In these
cases, the soft tissue graft counteracted the det-
rimental effect of the thin gingival phenotype
on horizontal bone loss39 and midfacial mucosal
recession, as evidenced by a systematic review by
Cosyn et al14. As a result, the differences between
grafted and non-grafted sites for bone thickness
and height were not statistically significant, except
for midbuccal bone thickness. The baseline charac-
teristics reveal that this difference existed from the
beginning in this region, favouring the grafted sites.
The midfacial region of the implant was specifically
involved, since the dimensional alteration pattern
in single extraction sites with healthy neighbouring
dentition was shown to occur mainly in the central
area of the socket wall40. This could also explain
why there was a significant difference between
the bone thickness changes in type I and II sockets
in this specific region after 2 years. Significant dif-
ferences between bone thickness changes in both
socket types were also observed apically, as no
changes were found in type I sockets, in contrast
to the significant changes seen in type II sockets
due to the added value of VST in this socket type in
particular. The technique also achieved a relatively
stable bone height for type  II sockets, as dem-
onstrated by the insignificant difference between
type I and II sockets and the insignificant changes
in bone height and thickness of type  II sockets
in the second year of follow-up. This was also
reflected in the results for PES and probing depth,
which showed an insignificant difference between
type I and II sockets.
The success of VST was further ensured by the
flapless computer-guided implant placement tech-
nique. The buccal bone plate, which is < 1.0 mm
thick in most cases5-6, receives its blood supply

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Elaskary et al Vestibular socket therapy in compromised sockets
from the periodontal ligament, the bone mar-
row and the outer periosteum41. When a tooth
is extracted, the blood supply comes only from
the periosteum. A flapless approach makes it pos-
sible to retain this last source and thus prevents
further bone and soft tissue loss. This contributed
to the high PES which, like probing depth, under-
went insignificant changes throughout the study
period34,42. A  PES of 12.48/14.00 was recorded
at the 2-year follow-up, in contrast to Buser et
al13 whose mean modified PES was 8.1/10.0 at
1 year after implant placement. The higher PES
in the present study may not only be attributed
to the bone shield used and the flapless design,
but also to the timing of implant placement; Buser
et al13 placed their implants 4 to 8 weeks after
tooth extraction and accompanied the procedure
with bone augmentation using autogenous bone
and deproteinised bovine bone mineral with col-
lagen membrane. In the present study, the instruc-
tions for good oral hygiene strictly followed by the
patients also led to the maintenance of a high PES
and a relatively stable probing depth; however, a
statistically significant difference between the cen-
tral and lateral incisor sites regarding the change in
PES was recorded in the second 6 months of the
study period, favouring the lateral incisor site. This
could be attributed to the dominance of the central
incisor, which makes it relatively more obvious to
patients and thus more liable to focus and criticism
than the lateral incisorr43.
A post hoc power analysis revealed that the
sample size of 27 implants was adequate to detect
significant differences in bone height and thickness
throughout the study period, with a P value < 0.001
and a power of 100%. The analysis decreased the
possibility of beta error. The ranges of the results
suggest some imprecision, however; thus, ran-
domised controlled trials with calculated sample
sizes comparing the effectiveness of this technique
with other control treatments are still required. A
follow-up period of a minimum of 5 years is also
recommended. Furthermore, given that the pres-
ent study was a single-arm study, blinding of the
assessor was not possible and should therefore be
ensured in future randomised controlled trials to
decrease the likelihood of assessment bias.
318
Conclusion
Within the limitations of the present study, it can
be concluded that combining immediate implant
placement with VST to manage compromised
fresh extraction sockets could provide promising
radiographic, aesthetic and peri-implant results
and minimise the treatment time and number of
surgical procedures required.
Acknowledgements
The authors thank Dr Amr Ekram, Oral and Max-
illofacial Consultant, for his participation in the
radiographic work included in the study.
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Copyright 2021, Quintessence Publishing Company, Ltd.
Elaskary et al Vestibular socket therapy in compromised sockets

Abdelsalam Elaskary, BDS Moataz Meabed, MDS

Founder, Elaskary and Associates Institute
and Clinic for Dental Implants and Oral
Reconstruction, Alexandria, Egypt; Visiting
Lecturer, College of Dentistry, University
of New York, New York, NY, USA
Periodontist, Private practice, Alexandria,
Egypt
Iman Abd-ElWahab Radi, PhD
Professor, Member of the Centre for
Evidence-Based Dentistry and Head of
Fundraising Unit and Central Control Unit,
Faculty of Dentistry, Cairo University,
Cairo, Egypt

Abdelsalam Elaskary

Correspondence to:
Prof Iman Abd-ElWahab Radi, Faculty of Dentistry, Cairo University, 11 El-Saraya St, El Manial, Cairo 11553, Egypt.
Email: iman.abdelwahab@dentistry.cu.edu.eg

Literature abstract
Int J Periodontics Restorative Dent 2020;41:589–597.
Karcı B, Öncü E, Dogan M. The effect of different dental implant surface characteristics on
bone immunologic biomarkers and microbiologic parameters: a randomized clinical study.

This study assessed the levels of tumor necrosis factor-_ (TNF-_), prostaglandin E2 (PGE2), receptor
activator of nuclear factor kappa B (RANK), RANK ligand (RANKL), osteoprotegerin (OPG), and levels
of Fusobacterium nucleatum, Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia,
Prevotella intermedia, and Streptococcus oralis in areas where airborne particle-abraded, large-grit,
acid-etched (SLA), fluorine-modified, and anodized implant surfaces are used. A total of 71 implants
from 37 patients were assessed, grouped according to the surface characteristics of the implants: SLA
surface (Group 1), fluorine-modified surface (Group 2), and anodized surface (Group 3). The following
clinical indices were measured: Gingival Index (GI), probing depth (PD), bleeding on probing (BOP),
clinical attachment level (CAL), and keratinized tissue width (KTW). Peri-implant sulcus fluid and sub-
gingival plaque samples were also collected. Commercial enzyme-linked immunosorbent assay (ELISA)
kits were purchased for measuring TNF-_, PGE2, RANKL, RANK, and OPG. Real-time quantitative
polymerase chain reaction (PCR) was used to detect P intermedia, T forsythia, T denticola, F nuclea-
tum, P gingivalis, and S oralis levels in the subgingival biofilms. The groups showed no statistically
significant differences in GI, PD, BOP, CAL, KTW, or peri-implant status. The total amounts of PGE2,
TNF-_, RANKL, RANK, and OPG and the RANKL/OPG ratio were not significantly different between
groups. F nucleatum, T forsythia, P intermedia, P gingivalis, and T denticola were significantly higher
in Group 3 implants. DNA concentrations of S oralis were higher in Group 2. Within the limitations of
this study, SLA and fluorine-modified implant surfaces may be more clinically successful than anodized-
surface implants. © 2020 Quintessence Publishing Co, Inc.

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