Utilization of Chronic Intrasocket Granulation Tissue for Immediate Implantation in the Type III Extraction Socket of a Maxillary Anterior Tooth Open Access

Intrasocket granulation tissue (IGT) is an internal soft tissue lining of the tooth extraction socket walls in chronic inflammatory conditions with endodontic or periodontic lesions.¹  IGT was considered infected tissue that should be debrided thoroughly after tooth extraction to promote socket healing and achieve successful bone regeneration from simultaneous alveolar ridge preservation or guided bone graft.²  Some studies have reported negative effects on wound healing, showing reduced bone formation, decreased osteogenic potential, and increased osteoclastic activity.³  Moreover, unwanted connective tissue or epithelial cell occupation may delay intrasocket bone regeneration.⁴  However, a few studies have demonstrated successful outcomes with primary closure achieved during bone augmentation using IGT.^5,6 

Granulation tissue is regarded as a contractile organ, distinguished histologically by the proliferation of fibroblasts, keratinocytes, endothelial cells, newly formed thin-walled capillaries, and the infiltration of inflammatory cells into the extracellular matrix.⁷  This tissue, a form of newly developed connective tissue containing microscopic blood vessels, serves 3 primary functions: (1) shields the wound surface from microbial invasion and additional damage; (2) rebuilds the wound from the base, introducing new tissue and blood vessels; and (3) acts as a temporary substitute for necrotic tissue until it is ultimately replaced by scar tissue.⁷ 

In periodontally compromised teeth, alveolar bone loss leads to inadequate soft tissue, necessitating bone grafting and primary closure immediately following implant placement. To support this, an absorbable barrier is employed to assist in implant placement and grafting, requiring a robust and sufficient flap to cover it. In addition, in periodontally compromised teeth, the pocket epithelium pathogenetically migrates in the apical direction with a host defense mechanism against microbial attack, and it becomes dense and thick, forming an altered pocket epithelium resembling the oral epithelium as a part of the gingival flap.⁸  Therefore, IGT could be utilized as an extended flap during tooth extraction as a socket cover with no additional soft tissue surgery and stable maintenance of the mucogingival junction level. Certain studies have reported primary closure using IGT during ridge preservation or ridge augmentation without releasing the incision into the flap or any vestibular depth change in the compromised extraction socket.^5,6,9 

Peri-implant dehiscence, which exposes the implant threads, poses a significant threat to dental implants’ long-term stability and success.¹⁰  As immediate implant placement in cases of buccal dehiscence often results in suboptimal therapeutic outcomes, ridge reconstruction should be considered to preserve alveolar bone and enhance implant stability.¹¹ 

The present case series aims to describe a helpful technique that employs chronic IGT for immediate implantation in a type III extraction socket¹²  within a maxillary anterior tooth.

This paper presents 3 cases in which chronic IGT was used for tooth extraction socket sealing after immediate implantation in periodontally compromised anterior teeth. The patient had no specific medical history but had severe bone defects due to chronic inflammation at the time of implant placement. In all cases, the IGT was high in buccal bone defects, reflecting the severity of the buccal bone defect, which was classified as a type III defect according to Elian et al,¹²  and was used as an extended gingival flap by unfolding the inner part of the thick IGT.

A 60-year-old man visited the dental clinic because of discomfort in the maxillary incisor (#21 according to the Federation Dentaire Internationale 2-digit tooth numbering system) and reported mobility and biting pain. Radiograph images revealed vertical bone resorption around the tooth and crown, and a dental post was placed after root canal treatment (Figure 1a). The tooth mobility was degree 2, and the buccal probing pocket depth was almost 9.0 mm (Figure 1b). The diagnosis was localized periodontitis of stage III and grade A based on the 2017 Classification of Periodontal and Peri-Implant Diseases and Conditions.¹³  The radiographic vertical bone loss was more than 3 mm with probing depths more than 6 mm, presumably due to a root fracture. After tooth extraction, friable granulation tissue was debrided using a surgical curette, and the extraction socket was cleaned with saline irrigation. A full-thickness buccal gingival flap was elevated using a P24G surgical elevator after a horizontal incision at the interdental papilla region (Figure 1c). A severe buccal bone defect was observed, and dense, thick IGT on the inner side of the buccal flap was partially separated using a horizontal incision with a #15c blade at first. Subsequently, additional vertical incisions were made on both sides to create an extended flap similar to a pedicle flap (Figure 1c). A dental implant (IU implant, Warantec, Korea) was immediately placed after socket debridement with an insertion torque value of 30 Ncm, bone graft material (Botiss Cerabone, Straumann GmbH, Freiburg, Germany) was filled at the buccal bone defect, and collagen membrane (Jason membrane, Straumann) was applied to cover the bone grafting site. Then, the socket was covered with extended granulation tissue and sutured using a 4-0 vicryl with an interrupted and x-suture method to secure the extended IGT. The IGT effectively sealed the socket without tension (Figure 1d and e). The implant fixture was well placed on the cone-beam computerized tomography image, and bone grafting was performed over the fixture (Figure 1f). One week after surgery, the stitches were removed, and favorable socket healing was observed in the extended granulation tissue (Figure 1g). After 3 months, an implant prosthesis was delivered (Figure 1h), and the implant condition was well-maintained until the 2-year follow-up (Figure 1i).

A 37-year-old woman requested a dental implant restoration for the maxillary incisor (#22), which had detached from the alveolar bone at the apical portion. A resin splint was applied to stabilize the mobile tooth (Figure 2a). The radiographic bone loss extended to the middle third of the root with a moderate ridge defect, and tooth loss was less than 4 teeth due to periodontitis. Although an overall alveolar bone resorption pattern was observed, the patient was not elderly and had no specific systemic diseases. The diagnosis was localized periodontitis of stage III and grade A, presumably due to trauma from occlusion. Tooth extraction was straightforward due to chronic inflammation, and a thick IGT was present on the buccal side (Figure 2b). The buccal IGT was prepared using the same method as in case 1 (Figure 2c). The implant (Osstem TSIII SA, Osstem Implant, Korea) was placed immediately following extraction with an insertion torque value of 30 Ncm (Figure 2c), accompanied by ridge augmentation with bone graft material (Bio-Oss collagen, Geistlich Pharma AG, Wohusen, Switzerland) and a collagen matrix (Collagen Graft 2, Genoss, Suwon, Korea) (Figure 2d). The extraction socket was entirely covered with the extended IGT and sutured using 4-0 vicryl with interrupted and x-suture techniques to secure the IGT (Figure 2e). Radiographic images confirmed the optimal positioning of the implant (Figure 2f) and that gingival healing was favorable 1 month postsurgery (Figure 2g). Three months later, the healing abutment was connected (Figure 2h), and the final implant prosthesis was delivered (Figure 2i).

A 75-year-old man presented with mobility of the maxillary incisor (#21) as his chief complaint (Figure 3a). The tooth exhibited mobility of degree 2 with supraeruption and labioversion caused by severe bone resorption, presumably due to an endo-perio combined lesion (Figure 3b). The diagnosis was generalized periodontitis of stage III and grade A based on the radiographic bone loss extending to the middle third of the root with moderate ridge defect, tooth loss due to periodontitis less than 4, and slow rate progression without smoking and diabetes. Following the extraction of #21, a dental implant (Luna S, Shinhung Co., Seoul, Korea) was immediately placed with an insertion torque value of 30 Ncm, utilizing a chronic IGT as an extended flap, applying the same method as in case 1 (Figure 3c). Bone graft material and a membrane were applied to the buccal defect. The flap was closed using a socket cover with an IGT, employing a horizontal mattress, x, and interrupted sutures to secure the IGT (Figure 3d). The implant placement was successful (Figure 3e), and a second surgery was performed 3 months later to connect the healing abutment (Figures 3f and 3g). The bone surrounding the implant demonstrated favorable conditions (Figure 3h), and an implant prosthesis was delivered (Figure 3i).

This case series showed that IGT could effectively cover extraction sockets as with an extended flap after immediate implantation into a periodontally compromised anterior region. According to a previous study,¹²  all 3 cases presented with type III sockets, indicating soft tissue dehiscence in the buccal wall that was either partially or fully damaged, which can lead to peri-implant dehiscence.¹⁴  Dehiscence defects must be carefully considered when placing implants in areas requiring esthetic consideration, such as the maxillary anterior teeth.¹⁵  Implants placed in areas with dehiscent defects experience 58% greater horizontal bone loss and a higher risk of gingival recession than those placed in areas with an intact buccal bone wall.¹⁶  Consequently, ridge augmentation is necessary when an implant is placed in an area with insufficient buccal bone.

In extraction socket types I and II, there is either no buccal bone loss or, if present, the buccal soft tissue remains intact. Consequently, primary closure is readily achievable with the existing soft tissue flap, eliminating the need for IGT. In this context, IGT is highly beneficial for type III extraction sockets, in which soft tissue and buccal bone are compromised. To carefully separate the IGT without causing damage, a round-tipped instrument, such as the GDC sinus lifting instrument No. 2 (GDC IMPSL2, India), can gently lift and separate the Schneiderian membrane from the maxillary bone. This action mimics lifting the sinus membrane by positioning the instrument on the bone beneath the extraction socket. Additionally, the periosteum can be elevated or detached from the underlying bone using a pushing motion, typically applied along the bone’s longitudinal axis.

When combined with particulate graft materials, resorbable collagen membranes demonstrate effective results in lateral alveolar ridge augmentation.¹⁷  Deproteinized bovine bone mineral (DBBM) with collagen membranes supports substantial new bone formation and high implant survival rates, providing a stable foundation for dental implants. Although implant survival rates are comparable between simultaneous and staged implant placement, simultaneous placement is recommended to streamline treatment and reduce the number of surgical interventions.

Based on the findings of a systematic review,¹⁷  the use of collagen membranes in guided bone regeneration (GBR) is supported by several factors. First, collagen membranes exhibit a lower rate of membrane exposure, which is crucial in GBR, as such exposure can increase the risk of infection and compromise the healing process. Previous animal studies demonstrate that DBBM combined with a collagen matrix promotes superior soft tissue regeneration and bone quality more effectively than DBBM paired with a collagen membrane.¹⁸  Consequently, in some instances, a collagen matrix was used instead of a collagen membrane.

Predictable bone regeneration requires primary wound closure to ensure unhindered healing.¹⁹  In particular, achieving tension-free primary closure can be challenging in the case of immediate implant placement owing to the limited volume of soft tissue.²⁰  Techniques such as soft tissue grafting,²¹  periosteal releasing incisions,²²  and vertical incisions can be used to close the extraction socket. However, these techniques may lead to undesirable outcomes, such as shallow vestibular depth and a decreased width of the keratinized mucosa after surgery.

Previous studies demonstrate that IGT provides notable benefits in achieving closure following bone grafting at tooth extraction sites.⁵  Surgical trauma is minimized by eliminating the need to elevate a soft tissue flap, thereby preserving the original soft tissue contour. Furthermore, a periosteal-releasing incision facilitates tension-free suturing of the wound edges, promoting more favorable healing outcomes.

In this study, using the IGT in immediate implant placement facilitated primary closure during ridge augmentation by utilizing a buccal flap without tension during socket sealing. Moreover, there are potential advantages in reducing the number of surgeries and shortening the treatment time. A significant advantage of this approach is maintaining the mucogingival junction level, which ensures the preservation of keratinized mucosa. A recently published controversial systematic review and meta-analysis identified an association between the absence of keratinized mucosa and an increased prevalence of peri-implantitis.²³  Consequently, the absence of keratinized mucosa should be recognized as a risk factor that increases the incidence of peri-implantitis, and maintaining keratinized mucosa during immediate implant placement with ridge augmentation can be considered an important factor.

However, the use of IGT is not feasible in all cases. Caution is advised for smokers as smoking may adversely affect periodontal regeneration,²⁴  and for diabetic or immunocompromised patients, healing may be delayed even in the absence of ongoing complications.^25,26  When the quantity of IGT is insufficient relative to the diameter of the socket opening, it cannot be employed for primary closure of the coronal soft tissue, necessitating alternative approaches.²⁷  Additionally, if the IGT is damaged during separation, its application becomes challenging. The use of IGT may be applied in premolars and molars; however, the entrance to the extraction socket often exceeds the size of the IGT, which may pose challenges in achieving adequate coverage and securing stability at the site.

Previous case series have treated either ridge preservation⁹  or peri-implant osseous defects²⁰  concurrently with IGT. However, this study distinguished itself by incorporating a bone graft material and barrier membrane in the immediate dental implant placement to replace a periodontally compromised anterior tooth. To gain scientific evidence while considering these advantages of IGT, a randomized clinical trial comparing this protocol with existing protocols, along with long-term follow-up, is necessary.

Using IGT as an extended flap in immediate implant placement for type III extraction sockets in healthy patients with anterior maxillae enables primary closure, enhances healing potential, and preserves keratinized mucosa with adequate vestibular depth.

CBCT:

cone-beam computerized tomography

FDI:

Federation Dentaire Internationale

IGT:

intrasocket granulation tissue

Sungtae Kim and Hee-seung Han contributed equally as first authors. This work was supported by Creative-Pioneering Researchers Program through Seoul National University and National Research Foundation of Korea (NRF) grant funded by the Korea government(MSIT) (No. RS-2024-00349549).

The authors declare no conflicts of interest.