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CLINICAL

A MODIFIED SOCKET SEAL SURGERY WITH

COMPOSITE GRAFT APPROACH
Carl E. Misch, DDS, MDS The contour of the residual ridge is reduced within 1 year by approximately 25%
Francine Dietsh-Misch, DDS,
in width after the extraction of a natural tooth. The augmentation of a tooth
MDS
Craig M. Misch, DDS, MDS socket after an extraction decreases the loss of available bone width for an
endosteal implant. Grafting at the same time as the extraction has benefits from
both a patient and doctor perspective. However, primary closure is more difficult,
KEY WORDS and may require the facial keratinized gingiva to be undermined and
approximated on the crest of the ridge, or the use of membranes, which are
Bone contour exposed during the soft tissue healing. The modified socket seal surgery uses a
Socket seal technique described by Landsberg and couples his procedure with autologous
Composite graft
bone harvested from the maxillary tuberosity. As a result, the tooth extraction
Dental exograft
socket may be augmented with autologous bone and connective tissue with a
simplified approach at the same time as the extraction of a tooth.

INTRODUCTION
he healthy natural tooth isting periodontal or endodontic dis-

Carl E. Misch, DDS, MDS, is the director of

the Misch Implant Institute, an associate
professor at the University of Pittsburgh, and
an adjunct professor at the University of
T stimulates the alveolar
bone, thus maintaining its
volume and density. The
removal of a tooth begins a
cascade of events within
the socket that will completely heal
with bone within 4 to 6 months.1 How-
ever, the final contour of the bone is
reduced in width by 25%.2 In addition,
ease or trauma from the extraction of-
ten destroy the labial bony plate and
causes the immediate loss of width and
height of bone, which may exceed 50%
of the optimum volume. The decrease
in width and height of bone can com-
promise replacing the tooth with an
implant. The diameter of the implant,
the implant position in relation to the
Alabama at Birmingham. He is also a as the epithelium migrates over the crest, and the cervical contour of the
diplomate of the American Board of Oral socket, the intraseptal bone is lost and crown for aesthetics and hygiene can
Implantology and is cochairman of the
International Congress of Oral Implantologists. the bone slopes from the higher lingual be directly affected by bone loss fol-
Address correspondence to Dr Misch at 751 aspect to the more apical facial cortical lowing the removal of teeth.
Chestnut, Suite 102, Birmingham, MI 48008. plate, which reduces the crestal height Several procedures have been sug-
Francine Dietsh-Misch, DDS, MDS, is in of bone.3 It is speculated this is due in gested to maintain adequate width and
practice at the Misch Implant Institute and is part to the constriction of the blood height of the alveolar ridge after ex-
an assistant professor at the University of
clot within the alveolus and the thin traction to insert endosteal implants.
Pittsburgh. Craig M. Misch, DDS, MDS, is
in private practice in Sarasota, Fla, and is an labial cortical plates remodeling in re- Misch and Dietsh4 suggest different
assistant professor at the University of sponse to inadequate blood supply af- graft materials based on the number of
Pittsburgh. ter the extraction. In addition, pre-ex- bony walls that remained after the

244 Vol. XXV/No. Four/1999

 Carl E. Misch et al

tooth is removed. A 5 bony wall defect mm connective tissue attachment). The ble. The socket walls are curretted to
will grow bone with almost any allo- inflammatory stage of healing is initi- remove remnants of the periodontal
plast, allograft, or autograft. When a ated by the extraction trauma. The crib- membrane, pathology, or granuloma-
labial plate is missing (4 bony wall de- riform plate of the tooth socket is com- tous tissue. A water-cooled, high-speed
fect), allograft or guided bone regen- posed of cortical bone and after the ex- handpiece and bur removes the epithe-
eration increases the predictability of traction is covered with the residual lium of the gingival socket walls and
restoring the original bony contour. A periodontal ligament (PDL). The socket exposes the vascularized connective
2 or 3 bony wall defect requires using fills with blood from the torn blood tissue. The socket walls are decorticat-
autogenous bone, and a block of autog- vessels originating from the PDL. The ed to expose the bone-forming cells in
enous bone fixated into position is re- blood coagulates and protects the bone the adjacent bone. A 3- to 5-mm thick
quired for 1 bony wall defects. during initial healing. graft of attached tissue that fits the ex-
The graft material placed into the The epithelium around the crest of traction site is harvested from the pal-
socket can become contamination or the alveolus migrates down the socket ate using a no. 15 scalpel blade. De-
graft material may be lost without pri- walls during the first week. The migra- mineralized freeze-dried bone is
mary closure. In order to achieve pri- tion continues until it reaches the bed packed into the socket until it reaches
mary closure over a bone graft at the of granulation tissue situated under the the crest of the bony socket walls. The
time of tooth extraction, a flap is rotat- blood clot formed from the bleeding attached tissue graft is placed over the
ed from the facial aspect of the alveo- vessels. It then migrates over this tis- socket and sutured into place. Sur-
lus. When the flap is closed, the kera- sue until it makes contact with the ep- geons should be aware that both air
tinized gingiva is placed over the sock- ithelium migrating from the other and water handpieces can cause air
et reducing the amount of attached tis- sides. Osteoclasts also gather along the emphysema and must be used with
sue on the facial aspect of the alveolus. crestal bone of the extraction site. caution.
It also requires incisions to close the The actual time for the healing of an The advantages of the SSS technique,
flap, which may deplete the blood sup- extraction socket varies between indi- according to Landsberg and Bichacho,7
ply to the very thin labial plate of bone. viduals. The number of bony walls are that the socket is completely sealed
Instead of repositioning a flap, the around the socket greatly influences and prevents physical interferences,
tooth can be extracted, allowing the the bone regeneration. Since the apical bacterial, or chemical contamination of
gingiva to granulate over the socket for region often has a 5 wall defect of bone the wound. The submucosa at the base
6 to 8 weeks following the extraction. and a good bony blood supply, its con- of the attached tissue graft acts as a
The advantages of the delaying the ditions are most conducive to form barrier to prevent undesirable penetra-
graft procedure is that the attached bone more rapidly. The size of the tion of epithelial cells into the socket.
gingiva will be newly formed second- socket also affects the rate of healing. This is prevented because the lamina
ary bony spongiosa, along with a de- Molars take longer to completely form propria of the graft heals with the con-
creased risk of infection. The disadvan- bone compared to anterior teeth. Teeth nective tissue in the socket gingival
tages of this technique are a 2-month with horizontal bone loss and a smaller walls. In addition, the soft tissue width
delay and additional surgery. The de- remaining root diameter heal faster and height of the ridge is preserved for
layed technique does not take advan- than teeth with a wider socket dimen- future implant restorations.
tage of the initial increase in bone for- sion; however the bone does not grow
COMPOSITE GRAFT SOCKET SEAL
mation rate from the regional accele- above the horizontal level of bone. The
SURGERY
ratory phenomenon (RAP) triggered by crestal aspect of bone healing is the
the trauma of the extraction.5 most variable as to the number of bony A modified socket seal surgery has
The soft and hard tissues of a tooth walls, blood supply, and absence of in- been developed by the author.8,9 A
socket heal by secondary intention. The fection. Yet it is the most important re- composite graft of connective tissue
healing sequence in both hard and soft gion for ideal implant placement. periosteum and bone is used to seal
tissue includes inflammation, epitheli- the socket. A connective tissue graft
SOCKET SEAL SURGERY
alization, fibroplasia, and remodeling.6 has the advantage over a keratinized
The sequential pattern of bone forma- Landsberg and Bichacho7 developed a graft by blending into the surrounding
tion prior to bone remodeling is ‘‘socket seal surgery’’ (SSS) for the attached gingival regions offering sim-
unique. maxillary anterior region. The SSS pro- ilar color and texture of the epithelium.
Oral epithelium surrounds the crest- cedure is preferably performed for in- This is most advantageous in the max-
al aspect of the socket and averages 3 tact socket walls (a 5 wall bony defect). illary anterior region and other aes-
mm in thickness in the absence of peri- The tooth is extracted with as atrau- thetic areas. The composite graft also
odontal disease (1 mm suillus, 1 mm matic a technique as possible and a contains autogenous bone. The major
junctional epithelial attachment, and 1 mucoperiostal flap is avoided if possi- advantage of autologous bone is a

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MODIFIED SOCKET SEAL SURGERY

246 Vol. XXV/No. Four/1999

 Carl E. Misch et al

more rapid and predictable bone for-

mation via osteogenesis. This tech-
nique is indicated any time a nonin-
fected tooth is extracted and an im-
plant is planned as replacement. It is
not indicated in cases of infection in
the socket area or if bone removal was
required to extract the tooth. In such
cases, grafting should follow a delayed
approach.
Five mL of venous blood is drawn
from the arm of the patient preopera-
tively. Place this into a multipurpose
centrifuge for 8 to 18 minutes. The
blood will be separated into 3 layers:
red blood cells on the bottom, buffy
coat in the middle, and serum on the
top. The buffy coat is composed of
platelets and white blood cells. Plate-
lets are a source of fibrin for the initial FIGURE 9. A periapical radiograph after 3 months demonstrates a lack of residual lamina
clot, and platelet-derived growth factor dura and complete healing.
(PDGF). PDGF acts as a chemo-attrac-
tant for mesenchymal cells involved in
bone formation. When PDGF is mixed tive tissue graft and helps prevent the mm in height) and the attached soft tis-
with DFDB, an increase of cartilage apical migration of epithelium within sue (about 3 mm in height) is trimmed
and bone formation has been report- the socket. The bone is then decorticat- of its epithelium with a tissue scissors
ed.10 ed at the apical and lingual cribriform leaving 3 mm of connective tissue at-
A modified composite graft tech- plates with a handpiece and surgical tached to the bone core (Figs 5–7).
nique for the socket seal surgery in- bur to increase the vascular bed and If the bone core does not fill the ex-
volves extraction of the tooth without ensure the RAP process (Fig 3). A 6- to traction socket completely, demineral-
periosteal elevation and minimal bone 10-mm trephine bur corresponding to ized freeze-dried bone and the buffy
loss. (The trauma from the extraction the extraction site diameter (Fig 4) is coat may be used in the apical portion
stimulates the rate of bone formation used in a slow-speed, high-torque of the socket, provided the labial plate
due to the RAP of bone repair.5) This handpiece to harvest a gingival graft is still intact (allografts are most pre-
is followed by curettage of all granu- with underlying bone. The most com- dictable in 5 wall bony defects). Since
lomatous tissue from the socket, espe- mon site for the intra-oral composite the new bone forms from the apical
cially the coronal and apical regions. If graft harvest is the maxillary tuberos- portion of the socket, this is the least
exudate is present, 2 or more weeks ity region. Care must be exerted not to important region to augment. If no
should be allowed elapse to insure that enter the antrum. This can be assured bone plate remains in the apical half of
a normalized pH is reacted and the by exposing local periapical radio- the socket, additional autogenous bone
risk of infection is reduced (Fig 1). The graphs with the assistance of 5-mm should be harvested from another in-
soft tissue epithelial lining around the steel ball templates. The trephine is traoral site to overfill the apical half of
extraction socket is debrided with a di- used as a lever to green stick fracture the socket. The bone of the composite
amond bur and handpiece under co- the bone core from its base. A Molt el- graft (connective tissue attached to
pious irrigation (Fig 2). This provides evator may also be used for this pur- periosteum and bone) is compressed
additional blood supply to the connec- pose. The bone core (usually 5 to 10 and fitted into the remaining portion

←
FIGURES 1–8. FIGURE 1. The tooth was extracted and the apical pathology curetted. A 2-week healing period decreases the risk of apical
pathology affecting the graft. FIGURE 2. A rough diamond is used to remove the keratinized lining of the gingival sulcus. FIGURE 3. A
long surgical bur is used to perforate the apical and palatal regions of the socket. FIGURE 4. A trephine drill is selected that corresponds
to the diameter of the socket. FIGURE 5. The tuberosity is the ideal harvest site. However, the tissue is often more than 3 mm thick. FIGURE
6. The tissue may be reduced in thickness before or after the graft is harvested. FIGURE 7. A trephine drill proceeds to the floor of the
antrum. The composite core is fractured at the base and removed with the bone periosteum and connective tissue. FIGURE 8. The core is
inserted into the socket and sutured into position.

Journal of Oral Implantology 247

MODIFIED SOCKET SEAL SURGERY

FIGURES 10–15. FIGURE 10. An intraoral view of the healed site after 3 months. FIGURE 11. Reflection of the tissue demonstrates a healed
socket, complete with cortical plate. FIGURE 12. A D3 implant is inserted with the attached abutment for cement retention. FIGURE 13. A
periapical radiograph of the implant in position. FIGURE 14. A 4-month re-entry of the composite graft in a maxillary central region.
FIGURE 15. A 5-mm-diameter D2 implant and abutment is inserted.

of the socket. The tissue of the com- graft is then sutured to the surround- The benefits of this modified tech-
posite graft will seal the socket and re- ing gingival tissue with facial and pal- nique permit the surrounding kerati-
main above the surrounding gingiva. atal interrupted 4–0 Vicryl sutures. A nized gingival tissues to migrate and
A mallet and blunt instrument should transitional prosthesis should not be form a similar color and texture of ke-
be used to tap it into place and com- permitted to load the tissue during the ratinized tissues over the socket. In ad-
press the bony core to conform to the first few weeks after extraction. Oth- dition, because autogenous bone is
crestal contour of the socket (Fig 8). erwise, the composite graft may be- used as the graft in the coronal half of
The connective tissue portion of the come mobile and sequestrate. the socket where the facial bone is

248 Vol. XXV/No. Four/1999

 Carl E. Misch et al

most often very thin or absent, more niques. Extractions of teeth lead to a
predictable results will result than if an rapid decrease in residual bone width.
allograft were used. As a result, re-en- Grafting the socket improves the prog-
try may be in 3 to 5 months, and place- nosis to maintain the width and height
ment of larger-diameter implants of remaining bone. However, primary
made possible. closure of the tissue is necessary for
The blood supply to the composite grafting to prevent contamination or
graft is established from the surround- loss of the graft material. When graft-
ing soft tissue and the broken vessels ing is performed at the same time as
of the PDL. Using these techniques all tooth extraction, the facial attached tis-
the advantages of the socket seal sur- sue is typically brought over the ex-
gery as presented by Lansberg and Bi- posed socket, resulting with less kera-
chacho7 are maintained and enhanced. tinized tissue, and stripping the peri-
osteum off the thinner labial plate of
DISCUSSION
bone. Delaying the graft for 2 months
The healthy, natural tooth maintains increases the amount of keratinized tis-
the alveolus. The unhealthy tooth often sue but delays treatment and adds an
loses a portion of the thin labial plate additional surgical procedure.
from disease or surgical trauma. The The socket seal surgery of Lands-
FIGURE 16. A periapical radiograph of the
D2 implant body in the central incisor po- more available bone, the larger the im- berg and Bichacho7 allows grafting at
sition. plant width, the better cervical esthet- the time of extraction without an ad-
ics, and ease of daily oral hygiene tech- ditional procedure and without kerati-

FIGURES 17–20. FIGURE 17. After 4 months, the abutment was reinserted into the implant body. FIGURE 18. A periapical radiograph of the
D3 implant in position. FIGURE 19. An intraoral periapical radiograph of the maxillary second premolar implant after 6 months of prosthetic
loading. FIGURE 20. An intraoral view of the final crown on the maxillary second premolar implant. A rubber band is used to orthodon-
tically move the molar anteriorly to a more favorable position.

Journal of Oral Implantology 249

MODIFIED SOCKET SEAL SURGERY

nized tissue decrease. However, a 5 appropriate healing time, the implant 6. Hupp J. Wound repair. In: Larry
bony wall extraction socket is desirable may be restored (Figs 17, 18). Six Peterson, ed. Contemporary Oral and
since an allograft is used in the socket. months postoperatively the patient’s Maxillofacial Surgery. St Louis: CV Mos-
The trauma of the extraction brings a progress was satisfactory (Figs 19, 20). by; 1993:60–70.
cascade of events to fill the socket with REFERENCES 7. Landsberg CJ, Bichacho NA. A
bone. Grafting at the same time takes modified surgical/prosthetic approach
1. Bhaskar SN. Orban’s Oral Histology for optimal single implant supported
advantage of this phenomenon. Graft-
and Embryology. 11th ed. St Louis, Mo: crown, part I. The socket seal surgery.
ing with autogenous bone accelerates
CV Mosby; 239–259. Pract Periodontic Aesthet Dent. 1994;6:11–
the bony repair and permits this pro-
2. Carlsson GE, Bergman B, Hede- 17.
cedure even when the labial plate is no gard B. Changes in contour of the max-
longer present. 8. Misch CE. The composite graft
illary alveolar process under immedi- socket seal surgery. Misch Implant In-
The graft site may be re-entered af- ate dentures. A longitudinal clinical stitute Surgical Manual. November 1996.
ter 3 to 5 months, depending upon the and x-ray cephalometric study cover- 9. Misch CE. Intraoral autogenous
size of the tooth root and the amount ing 5 years. Acta Odontol Scand. 1967; bone grafts for implant dentistry. In:
of autogenous bone in the composite 25:45–75. CE Misch, ed. Contemporary Implant
core (Figs 9–16). The site is often 3. Tatum OH. The Omnii Implant Sys- Dentistry. 2nd ed. St Louis: CV Mosby;
healed without evidence of a lamina tem. 1980. 1999.
dura and has a crestal cortical plate. 4. Misch CE, Dietsh F. Bone grafting 10. Howes R, Bowness JM, Groten-
Since the residual ridge width is main- materials in implant dentistry. Implant dorst GR, Martin GR, Reddi AH. Plate-
tained, a larger-diameter implant (5 Dent. 1993;2:158–167. let derived growth factor enhances de-
mm or more) often may be inserted, 5. Frost H. The regional acceleratory mineralized bone matrix and induces
which improves the facial contour and phenomenon: a review. Henry Ford Hosp cartilage and bone formation. Calcif
emergence of the final crown. After the Med J. 1983;31:3–9. Tissue Int. 1988;42:34–38. m

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