Is alveolar ridge preservation an overtreatment?

The morphology and dimensions of the postextraction alveolar ridge are important for the surgical and restorative phases of implant treatment. Adequate new bone formation and preservation of alveolar ridge dimensions following extraction will facilitate installation of the implant in a restorative position, while preservation of soft tissue contour and volume is essential for an aesthetic and implant-supported restoration with healthy peri-implant tissues. Alveolar ridge preservation (ARP) refers to any procedure that aims to: (i) limit dimensional changes in the alveolar ridge after extraction facilitating implant placement without additional extensive bone and soft tissue augmentation procedures (ii) promote new bone formation in the healing alveolus, and (iii) promote soft tissue healing at the entrance of the alveolus and preserve the alveolar ridge contour. Although ARP is a clinically validated and safe approach, in certain clinical scenarios, the additional clinical benefit of ARP over unassisted socket healing has been debated and it appears that for some clinicians may represent an overtreatment. The aim of this critical review was to discuss the evidence pertaining to the four key objectives of ARP and to determine where ARP can lead to favorable outcomes when compared to unassisted socket healing.

Alveolar ridge preservation with guided bone regeneration or socket seal technique. A randomised, single-blind controlled clinical trial.

OBJECTIVES: To compare radiographic bone changes, following alveolar ridge preservation (ARP) using Guided Bone Regeneration (GBR), a Socket Seal (SS) technique or unassisted socket healing (Control). MATERIAL AND METHODS: Patients requiring a single rooted tooth extraction in the anterior maxilla, were randomly allocated into: GBR, SS and Control groups (n= 14/). Cone Beam Computed Tomography (CBCT) images were recorded post-extraction and at 4 months, the mid-buccal and mid-palatal alveolar ridge heights (BARH/PARH) were measured. The alveolar ridge width, cross-sectional socket and alveolar-process area changes, implant placement feasibility, requirement for bone augmentation and post-surgical complications were also recorded. RESULTS: BARH and PARH was found to increase with the SS (0.65 mm ± 1.1/0.65 mm ± 1.42) techniques, stabilise with GBR (0.07 mm ± 0.83/0.86 mm ±1.37) and decrease in the Control (-0.52 mm ± 0.8/-0.43 mm ± 0.83). Statistically significance was found when comparing the GBR and SS BARH (p = .04/.005) and GBR PARH (p = .02) against the Control. GBR recorded the smallest reduction in alveolar ridge width (-2.17 mm ± 0.84), when compared to the Control (-2.3 mm ± 1.11) (p = .89). A mid-socket cross-sectional area reduction of 4% (-2.27 mm2  ± 11.89), 1% (-0.88 mm2  ± 15.48) and 13% (-6.93 mm2  ± 8.22) was found with GBR, SS and Control groups (GBR vs. Control p = .01). The equivalent alveolar process area reduction was 8% (-7.36 mm2  ± 10.45), 6% (-7 mm2  ± 18.97) and 11% (-11.32 mm2  ± 10.92). All groups supported implant placement, with bone dehiscence noted in 57% (n = 4), 64%(n = 7) and 85%(n = 12) of GBR, SS and Control cases (GBR vs. Control p = .03). GBR had a higher risk of swelling and mucosal colour change, with SS associated with graft sequestration and matrix breakdown. CONCLUSION: GBR ARP was found to be more effective at reducing radiographic bone dimensional changes following tooth extraction.

Small body size phenotypes among Middle and Later Stone Age Southern Africans.

Modern humans originated between 300 and 200 ka in structured populations throughout Africa, characterized by regional interaction and diversity. Acknowledgment of this complex Pleistocene population structure raises new questions about the emergence of phenotypic diversity. Holocene Southern African Later Stone Age (LSA) skeletons and descendant Khoe-San peoples have small adult body sizes that may reflect long-term adaptation to the Cape environment. Pleistocene Southern African adult body sizes are not well characterized, but some postcranial elements are available. The most numerous Pleistocene postcranial skeletal remains come from Klasies River Mouth on the Southern Cape coast of South Africa. We compare the morphology of these skeletal elements with globally sampled Holocene groups encompassing diverse adult body sizes and shapes (n = 287) to investigate whether there is evidence for phenotypic patterning. The adult Klasies River Mouth bones include most of a lumbar vertebra, and portions of a left clavicle, left proximal radius, right proximal ulna, and left first metatarsal. Linear dimensions, shape characteristics, and cross-sectional geometric properties of the Klasies River Mouth elements were compared using univariate and multivariate methods. Between-group principal component analyses group Klasies River Mouth elements, except the proximal ulna, with LSA Southern Africans. The similarity is driven by size. Klasies River Mouth metatarsal cross-sectional geometric properties indicate similar torsional and compressive strength to those from LSA Southern Africans. Phenotypic expressions of small-bodied adult morphology in Marine Isotope Stages 5 and 1 suggest this phenotype may represent local convergent adaptation to life in the Cape.

Bone volume changes after immediate implant placement with or without flap elevation.

OBJECTIVES: The aims of this prospective study were to evaluate bone dimensions after immediate implant placement with simultaneous grafting of the buccal gap, to determine if initial buccal bone width had an influence on bone remodelling and to compare bone volume changes using a flap or a flapless approach after 6 months of healing. MATERIAL AND METHODS: This prospective study included patients who required an extraction and a subsequent immediate implant placement at a non-molar site. In those cases where tooth extraction was not feasible with a flapless approach (test group) a mucoperiosteal flap was carefully elevated (control group). After extraction, a cone beam computed tomography (CBCT) was taken. Then, an implant was placed and the buccal gap was grafted using anorganic bovine bone. After 6 months of healing, a second CBCT was performed. A blinded investigator superimposed both images and performed a series of measurements to determine bone volume changes between the two time points. RESULTS: Thirty-five patients were included in this study, 20 of which belonged to the test group. All together, the differences between baseline and 6 months in buccal plate height, lingual plate height and in ridge width at 2, 4 and 6 mm were 0.48 ± 1.35; 0.58 ± 1.51; 0.64 ± 0.81; 0.59 ± 1.36 and 0.52 ± 1.16, respectively. Only a moderate correlation was observed between initial buccal plate width and buccal plate height at 6 months (P = 0.0001). No statistically significant differences were observed between flap and flapless approach. CONCLUSIONS: A mean reduction of around 0.5 mm in height and width after placing immediate implants and filling the residual gap with anorganic bovine bone may be expected. No significant association between initial buccal bone width and ridge width at 6 months was seen. No statistically significant differences were found between the two treatment protocols although more ridge reduction was observed for the flap group.