Definite treatment
The patient was an implant supported prosthesis candidate. Reevaluation six months later showed sufficient bone volume and soft tissue maturation ready for implant placement. Bone width in the implantation site was 6 mm and the height was 15 mm. A punch whole was made in the potential implant site and fixture was placed without flap reflection (Figure 2-a and b). Four months later, the implant was successfully loaded (Figure 2-c).
Socket preservation techniques have mostly concerned hard tissue augmentation and prevention of ridge collapse. Van der Weijden et al had a review of data about alveolar bone dimensional changes of extraction sockets in human. They calculated the data from 12 publications and reported an average 3.87 mm reduction in width and 1.67 mm bone loss in height after normal remodeling [15]. Soft tissue dimensional changes, however, has less been paid attention to through the literatures. The presence of adequate keratinized gingiva is of paramount importance in the long term survival of an implant, whereas a noticeable amount of buccal keratinized attached gingiva is coronally positioned to gain enough wound closure (GBR prerequisite) in conventional socket preservation techniques [16]. This is usually associated with complications like decreased vestibular depth, lack of adequate keratinized gingiva on the buccal side of the implant, and the coronal displacement of the mucogingival line which places a red alveolar mucosa tissue instead of a pink attached gingival [17]. This color mismatch poses an esthetic challenge and necessitates a second corrective graft surgery for buccal soft tissue augmentation. This also will be associated with a couple of post-operative problems e.g. scar tissue formation, compromised blood supply to the area, and excess costs [18]. The RPC graft technique presented in this paper will not only satisfy our need to prevent bone resorption but will also meet the soft tissue augmentation and preservation demands.
The main advantages of above mentioned technique could be summarized as:
• The epithelialized part of the pedicle graft covers the socket orifice and the de-epithelialized part is placed under the buccal flap. This not only ensures the proper closure of the socket, but also enhances the contour on the buccal side and contributes to the blood supply of the graft site. Underlying palatal graft will enhance the quality of the covering attached gingiva.
• The healing process then occurs through first intention on the socket orifice. It must be mentioned that one early clinical concern in all kinds of socket preservation procedures was wound premature opening [19].
• There is no need for releasing incisions since buccal flap is aimed to form a pocket.
• There is no need to coronally position the buccal flap. The mucogingival line level is then preserved as normal and buccal flap may even be positioned apically in an attempt to correct inadequate vestibular depth.
• Placing the non-epithelialized part of the pedicle graft under the buccal pocket beyond the mucogingival junction will make amends for the probable future buccal collapse.
• Due to adequate blood supply within the pedicle graft, socket inclusions will be nourished not only through socket walls but also from the flap. This will increase the chance of graft survival and enhance the future osseointegration in the potential implant site.
• This technique will not only provide sufficient functional masticatory mucosa but also will provide maximum buccal soft tissue augmentation (Figure 3).
• Future buccal depression results from the tissue collapse (which is an inevitable consequence of remodeling) will be prevented due to the overbuilding of soft tissue in the area.
• This technique along with the harvest of a thick graft in the mesial and distal donor pedicle, papillae generation could be achieved to some extent in patients where gingival papillae have become flattened.
• This technique is associated with esthetically pleasant outcomes since the connective tissue graft have the advantage of color matching to the overlying tissue (Figure 4).
• Adequately extended incisions along with the application of cut-back incisions will allow free rotation of the flap and its passive placement on the expected area. There is then no need to suture the graft in place. When needed, the flap end may be sutured using resorbable material to the underlying connective tissue.
• This technique usually does not need a coronal repositioning of the buccal flap and thus no mucogingival junction displacements would be expected [20]. The present (prior to extraction) attached gingiva will then be preserved and the papillae around the expected implant will be of sufficient height.
The possible modifications of this technique are as follows:
• Full thickness flap is suggested in cases where buccal marginal bone needs overbuilding and partial thickness flap is recommended where adequate intact (minimum of 2 mm) buccal table is present post-extraction [21].
• In the cases where the buccal table needs overbuilding, the socket width will be covered with a resorbable collagen membrane after bone graft is placed. However, if the buccal plate is intact, there is no need for buccal table overbuilding or membrane application.
• The socket may be filled with resorbable bone substitutes like DFDBA or semi-resorbable bone substitutes like nano-bone.
• There is then no need to suture the graft in place. When needed, the flap end may be sutured using resorbable material to the underlying connective tissue.
Based on the type of bone substitute used, a 3 to 6 month bone healing period should be considered prior to implantation [22]. Also, there is no need for another flap during implant placement and punch technique (as for the present case) will be sufficient. All techniques with high predictability and proper esthetic outcome would be selected in socket management procedures [23, 24].
