Clinical and histologic outcomes of socket grafting after flapless tooth extraction: A systematic review of randomized controlled clinical trials

Statement of problem. Several biomaterials and techniques have been reported for socket grafting and alveolar ridge preservation. However, the evidence for clinical and histologic outcomes for socket grafting with different types of materials in flapless extraction is not clear. Purpose. The purpose of this systematic review was to analyze the outcomes of a socket grafting procedure performed with flapless extraction of teeth in order to determine which graft material results in the least loss of socket dimensions, the maximum amount of vital bone, the least remnant graft material, and the least amount of connective tissue after a minimum of 12 weeks of healing. Secondary outcomes, including the predictability of regenerating deficient buccal bone, necessity of barrier membranes, and coverage with autogenous soft tissue graft, were also evaluated. Material and methods. An electronic search for articles in the English-language literature was performed independently by multiple investigators using a systematic search process with the PubMed search engine. After applying predetermined inclusion and exclusion criteria, the final list of randomized controlled clinical trials (RCTs) for flapless extraction and socket grafting was analyzed to derive results for the various objectives of the study. Results. The initial electronic search resulted in 2898 titles. The systematic application of inclusion and exclusion criteria resulted in 32 RCTs studying 1354 sockets, which addressed the clinical and histologic outcomes of flapless extraction with socket grafting and provided dimensional and histologic information at or beyond the 12-week reentry period. From these RCTs, the mean loss of buccolingual width at the ridge crest was lowest for xenografts (1.3 mm), followed by allografts (1.63 mm), alloplasts (2.13 mm), and sockets without any socket grafting (2.79 mm). Only 3 studies reported on loss of width at 3 mm below the ridge crest. The mean loss of buccal wall height from the ridge crest was lowest for xenografts (0.57 mm) and allografts (0.58 mm), followed by alloplasts (0.77 mm) and sockets without any grafting (1.74 mm). The mean histologic outcomes at or beyond the 12-week reentry period revealed the highest vital bone content for sockets grafted with alloplasts (45.53%), followed by sockets with no graft material (41.07%), xenografts (35.72%), and allografts (29.93%). The amount of remnant graft material was highest for sockets grafted with allografts (21.75%), followed by xenografts (19.3%) and alloplasts (13.67%). The highest connective tissue content at the time of reentry was seen for sockets with no grafting (52.53%), followed by allografts (51.03%), xenografts (44.42%), and alloplast (38.39%). Data for new and emerging biomaterials such as cell therapy and tissue regenerative materials were not amenable to calculations because of biomaterial heterogeneity and small sample sizes. Conclusions. After flapless extraction of teeth, and using a minimum healing period of 12 weeks as a temporal measure, xenografts and allografts resulted in the least loss of socket dimensions compared to alloplasts or sockets with no grafting. Histologic outcomes after a minimum of 12 weeks of healing showed that sockets grafted with alloplasts had the maximum amount of vital bone and the least amount of remnant graft material and remnant connective tissue. There is a limited but emerging body of evidence for the predictable regeneration of deficient buccal bone with socket grafting materials, need for barrier membranes, use of tissue engineering, and use of autogenous soft tissue grafts from the palate to cover the socket.