Osteology Consensus Report

Christoph H.F. Hämmerle Evidence-based knowledge on the

Authors’ affiliations: Key words: bone regeneration, clinical research, clinical trials, guided tissue regeneration,
Christoph H.F. Hämmerle, Center of Dental wound healing
Medicine, Clinic of Fixed and Removable
Prosthodontics and Dental Material Science,
University of Zurich, Zurich, Switzerland Abstract
Mauricio G. Araujo, Department of Dentistry, State
University of Maringá, Parana, Brazil
Objectives: The fresh extraction socket in the alveolar ridge represents a special challenge in
Massimo Simion, Departmet of Periodontology, everyday clinical practice. Maintenance of the hard and soft tissue envelope and a stable ridge
IRCCS Cà Granda Foundation – Ospedale Maggiore volume were considered important aims to allow simplifying subsequent treatments and
Policlinico, Department of Reconstructive, Surgical
and Diagnostic Science, University of Milan, optimizing their outcomes in particular, when implants are planned to be placed.
Department of Periodonology, College of Dentistry, Material and Methods: : Prior to the consensus meeting four comprehensive systematic reviews
King Saud University, Riyadh, Saudi Arabia were written on two topics regarding ridge alteration and ridge preservation following tooth
Mauricio G. Araujo, Department of Dentistry, State
University of Maringá, Parana, Brazil extraction and implant placement following tooth extraction. During the conference these
manuscripts were discussed and accepted thereafter. Finally, consensus statements and
Corresponding author: recommendations were formulated.
Mauricio G. Araujo
Department of Dentistry Results: : The systematic reviews demonstrated that the alveolar ridge undergoes a mean
State University of Maringá horizontal reduction in width of 3.8 mm and a mean vertical reduction in height of 1.24 mm
Parana, Brazil
within 6 months after tooth extraction. The techniques aimed at ridge preservation encompassed
Tel.: +41 44 634 32 51
Fax: +41 44 634 43 05 two different approaches: i) maintaining the ridge profile, ii) enlarging the ridge profile.
e-mail: [email protected] Regarding timing of implant placement the literature showed that immediate implant placement
leads to high implant survival rates. This procedure is primarily recommended in premolar sites
Conflicts of interest with low esthetic importance and favorable anatomy. In the esthetic zone, however, a high risk for
The authors declare no conflicts of interest. mucosal recession was reported. Hence, it should only be used in stringently selected situations
with lower risks and only by experienced clinicians. In molar sites a high need for soft and hard
tissue augmentation was identified.
Conclusions: : Future research should clearly identify the clinical and patient benefits resulting
from ridge preservation compared with traditional procedures. In addition, future research should
also aim at better identifying parameters critical for positive treatment outcomes with immediate
implants. The result of this procedure should be compared to early and late implant placement.

The fresh extraction socket in the alveolar the ridge following tooth extraction. Further-
ridge represents a special challenge in every- more, this consensus analyzed the clinical
day clinical practice. Regardless of the subse- outcomes of implant placement into sockets
quent treatment maintenance of the ridge at different time spans following tooth
contour will frequently facilitate all further extraction.
*Osteology Consensus Group 2011: Mauricio G. Araújo, steps of therapy. This is particularly true for
Maringa, Parana, Brazil; Dieter Bosshardt, Daniel Buser,
Berne, Switzerland; William V. Giannobile, Ann Arbor,
treatments involving the placement and
Michighan, USA; Reinhard Gruber, Vienna, Austria; Chr- reconstruction of dental implants. It has been Workshop discussion and
istoph H.F. Hämmerle, Ronald E. Jung, Zürich, Switzer-
land; Niklaus P. Lang, Hong Kong SAR PRC; Myron demonstrated in numerous animal and clini- consensus
Nevins, Boston, Massachusetts, USA; Friedrich Neukam, cal studies in humans that following tooth
Nuremberg, Germany; Mariano Sanz, Madrid, Spain;
Massimo Simion, Milano, Italy; Georg Watzek, Vienna, extraction undisturbed wound healing will The group discussing the evidence and gener-
Austria lead to loss of ridge volume and change in ating the consensus statements consisted of
Date: ridge shape. individuals competent in different disciplines
Accepted 8 October 2011 The aim of the present consensus report of medical dentistry with a special emphasis
To cite this article: was to critically evaluate the scientific evi- on implant therapy. Prior to the consensus
CHF Hämmerle, Araújo MG, Simion M, On Behalf of the
Osteology Consensus Group 2011. Evidence-based knowledge
dence regarding ridge alterations following meeting, two groups of researchers wrote
on the biology and treatment of extraction sockets. tooth extraction and to assess the effects of comprehensive systematic reviews on two
Clin. Oral Impl. Res. 23(Suppl. 5), 2012, 80–82
doi: 10.1111/j.1600-0501.2011.02370.x treatment strategies aiming at preservation of topics each regarding ridge alterations and

© 2011 John Wiley & Sons A/S 80

ridge preservation following tooth extraction (i) Generation of a good soft tissue volume Regarding indication other than the ones
and implant placement following tooth for the time of implant placement thus mentioned above, there is little or no evi-
extraction. simplifying implantation procedures at dence.
During the conference, the reviewers first earlier time points.
presented their manuscripts explaining how (ii) Generation of a good hard tissue volume Clinical recommendations regarding ridge
the literature search was conducted, how the for the time of implant placement thus preservation
In general, the group made the following clin-
data were extracted, analyzed, which results simplifying implantation procedures at
ical recommendations:
were found and which conclusions could be later time points.
drawn. The entire group then discussed these
No high level evidence was found in the • Raising of a flap and placement of bioma-
reports. Thereafter, all four manuscripts were terials (biomaterial for ridge contouring
literature regarding contraindications specific
accepted. Another thorough discussion fol- and/or barrier membrane).
for ridge preservation. Hence, the group made
lowed on published data on lower levels of
the following consensus. • Primary would closure.
evidence than the one included in the manu-
Contraindication for ridge preservation was • Materials with a low resorption and
scripts and its impact on the conclusions to replacement rate.
considered to encompass:
be drawn. Finally, the group formulated con- • Raising of flaps and placement of a
sensus statements and recommendations for • General contraindication against oral sur- device/devices for contouring the ridge
clinical practice and for future research. gical interventions. profile.
Furthermore: Regarding the different materials applied in

Ridge preservation
• Infections at the site planned for ridge
clinical studies the systematic review did not
show significant differences between the var-
preservation, which cannot be taken care
ious materials, (i.e., filler, membranes) except
of during the ridge preservation surgery.
Definition of terms
The group considered it important to define
• Patients radiated in the area planned for
for the collagen plug alone, which revealed
negative results.
ridge preservation.
terms regarding the various procedures,
which previously had been described in the
• Patients taking bisphosphonates.
Although primary wound closure was gen-
erally considered an important factor for suc-
literature under the general term of “ridge Various techniques have been described in cess, the literature did not allow a
preservation.” It was obvious that a distinc- the literature for so called ridge preserva- meaningful comparison of different tech-
tion needed to be made as described below. tion. These techniques may be categorized niques for primary wound closure (soft tissue
Ridge preservation = preserving the ridge into two different groups: (i) techniques aim- punch, connective tissue graft, barrier mem-
volume within the envelope existing at the ing at maintaining the ridge profile (ridge brane, soft tissue replacement matrix).
time of extraction preservation), (ii) techniques aiming at
Ridge augmentation = increasing the ridge enlarging the ridge profile (ridge augmenta-
tion). Future research regarding ridge preservation
volume beyond the skeletal envelope existing
Regarding future research the consensus sta-
at the time of extraction To enlarge the ridge profile flaps have
ted the following:
generally been raised and augmentation pro-
Consensus statements regarding ridge cedures using biomaterials for ridge contour- • Focus on patient centered outcomes.
preservation
The systematic review by Lang et al. (2012)
ing with or without barrier membranes • Focus on clinical short-, medium-, and
have been performed. It appears that pri- long-term outcomes including biological,
demonstrated that based on clinical studies
mary closure of the wound is beneficial technical, phonetic, and esthetic parame-
the alveolar ridge undergoes the following
regarding the volume gained applying this ters.
dimensional changes within 6 months after
tooth extraction:
approach. • Studies regarding possible benefits during
These indications were identified for ridge subsequent implant therapy encompass-
• Mean horizontal reduction in ridge width: preservation: ing:
3.8 mm.
• Implant placement is planned at a time
•
(i) Assessing the need for further hard and
Mean vertical reduction in ridge height: point later than tooth extraction i.e., soft tissue augmentation
1.24 mm.
(ii) Assessing the amount of further hard
(i) When immediate or early implanta-
Based on the systematic review by Vigno- and soft tissue augmentation.
tion is not recommendable
letti et al. (2012) the group concluded that (iii) Assessing esthetic outcomes.
(ii) When patients are not available for
the reasons for ridge preservation included:
the immediate or early implant • Conditions of the soft tissues, i.e., dis-
• Maintenance of the existing soft and hard placement (pregnancy, holidays, …) placement of the muco-gingival junction,
tissue envelope. (iii) When primary stability of an color of the ridge mucosa, amount of ker-
• Maintenance of a stable ridge volume for implant cannot be obtained atinized mucosa.
optimizing functional and esthetic out- (iv) In adolescent people • Techniques for soft tissue management, i.
comes.
• Contouring of the ridge for conventional
•
e., raising of flaps yes/no.
• Simplification of treatment procedures prosthetic treatment.
Method for soft tissue closure.
subsequent to the ridge preservation
• Provided the cost/benefit ratio is positive. • Influence of the hard and soft tissue anat-

• Reducing the need for elevation of the

© 2011 John Wiley & Sons A/S 81 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/80–82
Hämmerle et al
Evidence for treatment of extraction sockets

ness of the bony socket walls, soft tissue • Several risk factors for the development In areas of esthetic priority implant installa-
area, volume, color, scars. of mucosal recession have been identified: tion into the fresh extraction socket (Type I
• Effect of various biomaterials applied for (i) Smoking placement) is not recommended.
ridge contouring. (ii) Presence of a thin buccal bone plate Several published prospective case series
• Effect of various biomaterials applied as (i.e., <1 mm thick) not included in the present systematic review
barrier membranes. (iii) Presence of a thin soft tissue biotype using the early implant placement protocol
• Methodological studies on the optimal (iv) Facial implant position have reported intermediate to long-term
type of measurements to assess the out- excellent esthetic results (Belser et al. 2009;
come of treatment regarding soft tissue • Augmentation of soft and hard tissues is Buser et al. 2011). These results lend addi-
and hard tissues. frequently necessary. tional support to the recommendation of type
• Development of consistent reference • The procedure of immediate implant place- II instead of type I implant placement follow-
points for 3D imaging technologies, when ment into extraction sockets should be ing tooth extraction in esthetic sites.
studying changes in ridge morphology used very restrictively in the esthetic area.
regarding soft and/or hard tissues. Limited to posterior sites the systematic
Future research regarding timing for implant
• Studies on the normal anatomy regarding review by Lau et al. 2012 lead to the follow-
placement
These recommendations are valid for both
bone and soft tissue thickness and types ing conclusions: anterior and posterior sites.
in different regions of the jaws.
• Studies on the effects of different extrac- • For single tooth implants high survival
• Reporting of frequency analyses of com-
tion techniques on subsequent healing. and low complication rates have been plication should become standard.
• Identify the most appropriate control reported.
• Studies addressing immediate implanta-
group for pre-clinical and clinical studies. • Molar sites present situations with lim- tion in the absence of risk factors.
ited indications due to anatomical rea-
sons.
• Comparison of surgical approaches with
and without the elevation of flaps.
Timing for implant placement • When immediate implants are placed in
• Comparison of surgical approaches with
molar sites, soft and hard tissue augmen- and without filler materials in the gap
Two systematic reviews were available (Lau tation is frequently necessary. between the buccal aspect of the implant
et al. 2012; Sanz et al. 2012) regarding timing • Premolars represent the sites with the and the buccal bone wall.
of implant placement into extraction sockets. most favorable indication due to the nor-
mally favorable anatomical situation and
• Assess the influence of the distance of
Both reviews focused on the highest level of the implant to the buccal bone wall on
scientific evidence and were conducted with the generally low esthetic demands. bone formation.
reasonable and clearly defined inclusion and The treatments of fully edentulous jaws • Comparison of different filler materials in
exclusion criteria. and of multiple extraction sites have not different clinical situations.
been duly addressed in the literature. • Comparison of type 1 (immediate) and
Consensus statements regarding timing for type 2 (early) implant placement in low
implant placement
Clinical recommendations regarding timing for risk situations.
Limited to esthetic sites the systematic
reviews lead to following conclusions:
implant placement
As based on the literature the group con-
• Comparison of type 2 (early) and type 3
(delayed) implant placement.
• Immediate implant placement leads to
cluded that in situations, where no risk fac-
tors are present (situations rarely occurring),
• Identify the ideal clinical protocols and
high implant survival rates. the best biomaterials for type 1, type 2,
• Immediate implant placement is associ-
this procedure may be recommended for
and type 3 implant placement.
ated with a high risk for mucosal recession.
experienced clinicians.
Immediate implant placement is primarily
• Changes in the contours of the ridge over
A wide range regarding the amount of extended periods of time.
recommended in premolar sites with low
recessions is reported in the literature.
esthetic importance and favorable anatomy.

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82 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/80–82 © 2011 John Wiley & Sons A/S