Collagen Plugs for Socket Preservation: Benefits and Indications?

This Week in Implants
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What role do collagen plugs play in socket preservation and can other biomaterials enhance the benefits of collagen plugs?

Socket preservation is a surgical procedure aimed at limiting the physiological resorption of the alveolar ridge that occurs after a dental extraction. One of the primary goals is to maintain sufficient bone volume to facilitate future implant placement. The procedure helps compensate for the resorption of the facial bone wall. The socket preservation procedure involves the use of various biomaterials to prevent bone resorption and accelerate bone formation.

Suggested Treatment Options for various Socket Type situations

Source: Classification Based on Extraction Socket Buccal Bone Morphology and Related Treatment Decision Tree Materials (Basel). 2022 Jan 19;15(3):733. - Larissa Steigmann 1, Riccardo Di Gianfilippo 1, Marius Steigmann 2, Hom-Lay Wang 1

Illustration of ST-Classification with suggested treatment options.
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Illustration of ST-Classification with suggested treatment options. (**A** ): ST1A. Extraction socket with thick (≥1 mm) and intact buccal bone. No further treatment is needed. Optionally, a collagen matrix may be placed to facilitate homeostasis. B showed the management of ST1B socket. (**B** ): Thin (<1 mm) and intact buccal bone. Suggested treatment option is a particulate grafting material with collagen dressing on the coronal aspect. The collagen plug is secured by a cross suture as illustrated. (**C** ): Buccal bone with a bony fenestration regardless of buccal bone thickness. An absorbable membrane (marked in white) is placed inside the socket and, subsequently, particulate grafting material is added. The membrane is sutured to the palatal tissue using single interrupted suture. Treatment for ST3 sockets is reported in D–F. (**D** ): The length of the dehiscence is ≤1/3 of buccal bone height. The recommended therapeutic approach coincides with the description of C. (**E** ): Buccal dehiscence extends >1/3–2/3 of buccal bone height. At this point, the utilization of a non-resorbable d-PTFE membrane (marked in blue) is indicated. The membrane is positioned below the tunneled soft tissue and on top of the buccal bone covering the bone-grafting material. A cross suture is placed on top of the d-PTFE membrane. (**F** ): Dehiscence surpasses ≥2/3 of buccal bone height. At this point, flap elevation is required and a d-PTFE membrane (marked in blue) is placed on top of the bone-grafting material and covered by a cross suture. The membrane is left in place for 4–6 weeks according to physiologic bone maturation. (Abbreviations. B: native bone. BG: particulate bone grafting. CP: collagen plug. CM: collagen membrane. d: dense polytetrafluoroethylene membrane.)

The Socket Plug Technique

Source: Classification Based on Extraction Socket Buccal Bone Morphology and Related Treatment Decision Tree Materials (Basel). 2022 Jan 19;15(3):733. - Larissa Steigmann 1, Riccardo Di Gianfilippo 1, Marius Steigmann 2, Hom-Lay Wang 1

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(**A** ): Clinical view of alveolar socket after extraction of a second molar. The buccal bone was preserved in height but thinner than 1.0 mm. The case was classified as Socket type 1B (ST1B). (**B** ): The socket was filled with particulate bone-grating material and coronally sealed with a collagen plug. (**C** ): Surgical re-entry at the time of implant placement showed successful ridge preservation.

Extraction and PRF with Collagen Plug

Source: A clinico-radiographic and histomorphometric analysis of alveolar ridge preservation using calcium phosphosilicate, PRF, and collagen plug Maxillofac Plast Reconstr Surg. 2019 Sep 2;41(1):32. - Tarun Kumar AB 1, Chaitra N T 2, Gayatri Divya PS 3,:email:, M G Triveni 1, Dhoom Singh Mehta

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Pre-operative radiographic (a) and clinical representation of premolar indicated for extraction (b). Atraumatic extraction done (c) using the Benex extraction system (d) followed by socket grafting with calcium phosphosilicate biomaterial (e pointed using arrow) and PRF placement (f)

Summary

Benefits of Collagen Plugs

The main benefits of a collagen plugs are:

  • Wound Healing: Collagen is highly biocompatible, meaning it integrates well with the body’s tissues without causing adverse reactions. Its hemostatic properties help in controlling bleeding, which is crucial for clot formation and wound stabilization.
  • Tissue Regeneration and Socket Stability: By filling the extraction socket, collagen plugs help stabilize the area, preventing the collapse of the surrounding tissues. This stability is important for maintaining the dimensions of the socket, which is beneficial for future dental implant placement. Furthermore, collagen plugs provide a scaffold that supports the growth of new bone and soft tissue and serves as a chemotactic agent for fibroblasts.

Collagen Plugs: To Graft or Not?

Intact buccal bone and Thickness

Because of the above mentioned benefits of collagen plugs, various protocols have been suggested based on the clinical case and the socket type classification (ST). Interestingly, in cases of an extraction socket with intact buccal bone and with buccal bone thickness of ≥1.0 mm, research suggests that simply using a collagen-based material, like a collagen plug is sufficient and no further grafting is necessary. However, in cases of intact buccal bone with buccal bone thickness of <1.0 mm, some type of grafting will be necessary. A suggested technique, in this situation, is the socket-plug technique. The basic steps of the “socket-plug” technique consist of atraumatic tooth extraction, placement of the appropriate biomaterials in the extraction site, preservation of soft tissue architecture employing a flapless technique, and placement and stabilization of the collagen plug with an appropriate suture technique. Various studies have shown that this technique is effective for socket augmentation.

Buccal bone fenestration or Dehiscence

Finally, it is very important to note that in all other cases, where the buccal bone is NOT intact, such as buccal bone fenestration or dehiscence, some type of more advanced grafting procedures is required. We will address these techniques in a future post, as this beyond the scope of this particular topic (but, see the decision tree below)

Using Collagen Plugs with PRF

One interesting technique to mention is the use of PRF in conjunction with collage plugs, which has been the subject of various studies. One study indicated that PRF combined with a collagen plug was more effective in preserving bone width compared to PRF alone, although the overall differences in bone height and density were not statistically significant. Another study highlighted the efficacy of using a collagen plug with PRP (platelet-rich plasma) in socket preservation, showing reasonable outcomes in preserving the alveolar ridge. Overall, the combination of PRF and a collagen plug appears to enhance the clinical outcomes in socket preservation procedures, but further research with larger sample sizes is needed to substantiate these findings. For those interested in learning more about collagen plugs and PRF, you maybe interested in this video PRF Sticky Collagen Plugs.

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