medicina

Case Report
Flap Extension Technique Using Intrasocket Granulation Tissue
in Peri-Implant Osseous Defect: Case Series
Won-Bae Park 1 , Jung-Min Ko 2 , Ji-Young Han 3 and Philip Kang 2, *

1 Department of Periodontology, School of Dentistry, Kyung Hee University, Private Practice in Periodontics
and Implant Dentistry, Seoul 02447, Korea
2 Division of Periodontics, Section of Oral, Diagnostic and Rehabilitation Sciences, Columbia University
College of Dental Medicine, New York, NY 10032, USA
3 Department of Periodontology, Division of Dentistry, College of Medicine, Hanyang University,
222-1 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea
* Correspondence: [email protected]

Abstract: A compromised extraction socket is characterized by severe bone resorption around

neighboring teeth and is often occupied with thick intrasocket granulation tissue (IGT). Guided bone
regeneration (GBR) is a procedure that can preserve the bone volume around extraction sockets, and
it can also be combined with immediate implant placement. However, an early exposure of GBR
sites is a possible complication because it increases the risk of infection and can inhibit successful
bone regeneration. The purpose of these case series is to introduce a novel, surgical procedure that
can prevent the exposure of GBR sites by using IGT for flap extension during immediate implant
placement in compromised extraction sockets. The technique was successfully performed in six
patients. For successful flap closure, the inner portion of the IGT was dissected so that the flap was
properly extended with the base of IGT attached to the flap for blood supply. Periosteal releasing
Citation: Park, W.-B.; Ko, J.-M.; Han, incisions were not performed. The IGT was first sutured to the palatal flap with resorbable sutures,
J.-Y.; Kang, P. Flap Extension and then the overlying flap was closed with additional sutures. There was no post-operative exposure
Technique Using Intrasocket of the surgical GBR site in any of the patients, and the location of the mucogingival junction remained
Granulation Tissue in Peri-Implant unchanged. All grafted sites also achieved sufficient bone regeneration. Within the limitations, this
Osseous Defect: Case Series. Medicina case series demonstrates the potential use of IGT, a concept which was previously obsolete.
2022, 58, 1555.
https://doi.org/10.3390/ Keywords: dental implants; socket graft; surgical flap; granulation tissue; bone regeneration; surgical
medicina58111555 closure technique
Academic Editors: Simone
Marconcini and Bruno Chrcanovic

Received: 19 August 2022

1. Introduction
Accepted: 26 October 2022
Published: 29 October 2022
Guided bone regeneration (GBR) is a predictable concept that can be applied in the
treatment of various peri-implant osseous defects including in extraction sockets during
Publisher’s Note: MDPI stays neutral
immediate implant placement. GBR uses bone grafts for space maintenance and barrier
with regard to jurisdictional claims in
membranes for epithelial cell exclusion [1,2]. Various factors can affect the outcome of the
published maps and institutional affil-
GBR procedure including the choice of bone graft and barrier membrane, the size and shape
iations.
of the defect, the thickness of the flap and the achievement of primary closure, and the
operator’s clinical experience level [3]. In particular, the sophistication of flap management
by the operator is of great importance to the success of GBR procedures, especially in
Copyright: © 2022 by the authors.
cases of immediate implant placement as achieving tension-free primary closure can be
Licensee MDPI, Basel, Switzerland. challenging due to limited soft tissue volume.
This article is an open access article Immediate implant placement is often performed due to its many advantages over de-
distributed under the terms and layed implant placement, especially in the maxillary anterior region. Immediate placement
conditions of the Creative Commons minimizes resorption of the buccal bone plate and enables successful bone augmenta-
Attribution (CC BY) license (https:// tion [3,4]. On the other hand, delayed placement has its advantage of allowing better
creativecommons.org/licenses/by/ flap closure; however, several additional procedures are sometimes required to restore the
4.0/). esthetics due to soft tissue or hard tissue deficiencies after resorption of the thin buccal bone

Medicina 2022, 58, 1555. https://doi.org/10.3390/medicina58111555 https://www.mdpi.com/journal/medicina

Medicina 2022, 58, 1555 2 of 11

plate. Therefore, although technique-sensitive, immediate placement can be considered

preferentially for implant placement after extraction in the esthetic zone.
Primary closure in GBR of extraction sockets can be achieved with several techniques
like using periosteal releasing incisions [5], a combination of periosteal releasing incisions
and vertical incisions, or a soft tissue graft [6]. However, these techniques may cause
unfavorable results post-operatively including the shallowing of the vestibular depth and
the decrease in the width of keratinized mucosa. Technical modifications in the GBR
procedure have been proposed to compensate for these shortcomings including using
granulation tissue of the extraction socket for flap extension. Mardinger et al. [7,8] and
Hur et al. [9] reported that intrasocket granulation tissue (IGT) in a compromised extraction
socket could be used to make primary closure possible during ridge augmentation at time
of implant placement or ridge preservation before implant placement without changing
the vestibular depth.
It is also a common belief that it is not safe to place the implant immediately into a
periodontally compromised socket because of the lack of sufficient bone. Mardinger et al. [8]
reported that implant placement was performed 6 months after ridge preservation of a
periodontally compromised socket. Additionally, An et al. [10] reported that a compromised
socket of a premolar or molar achieved sufficient vertical and horizontal bone gain one year
after extraction. These suggest that a compromised socket takes a long time to heal and
achieve suitable dimensions for implant placement if only ridge preservation is completed.
From the knowledge of the authors, the surgical technique of utilizing intrasocket
granulation tissue described in this case report has not been widely recognized among
clinicians. However, to increase the success of GBR cases around compromised extraction
sockets, the surgical site must remain unexposed and primary closure must be maintained
until the time of uncovering. This case report introduces the flap extension method using
the IGT of a compromised extraction socket for successful primary closure and evaluates
its clinical and radiological results in six patients.

2. Detailed Case Description

Six patients underwent extraction, immediate implant placement, and guided bone
regeneration (GBR) using intrasocket granulation tissue (IGT) for flap extension and pri-
mary closure. Patient information including age, sex, smoking status, site of compromised
socket, implant information, and follow up period is shown in Table 1.

Table 1. Patient information.

Compromised Follow-Up
Case Age/Sex Smoking Implant Size
Socket Site Period (Months)
1 52/M No #21 3.8 × 12 12
2 53/F No #23 3.8 × 10 29
3 72/M Yes #13 3.8 × 12 35
4 76/F No #13 3.8 × 12 28
5 54/M Yes #36 4.3 × 10 19
6 72/F No #35/#36 4.3 × 10 26

The surgical method used in each patient is as follows:

1. A tooth or implant with severe bone loss was removed using extraction forceps under
local anesthesia with 2% lidocaine containing 1:100,000 epinephrine;
2. A midcrestal incision and two buccal vertical incisions were made. Before raising the
flap, special care was taken to ensure a clean dissection of the IGT from the underlying
flap without any damage and the IGT is still well-attached to the flap. The IGT
was then further separated from the bony housing by using a curette with various
curvatures and a periosteal elevator.
3. The IGT attached to the buccal flap was dissected to an appropriate thickness using a
#15 blade so that the base of the IGT was still attached to the existing flap, and the
Medicina 2022, 58, 1555 3 of 11

flap was eventually extended. Periosteal releasing incisions were not performed at
the flap base.
4. The extraction socket was thoroughly debrided using a Molt curette and a tita-
nium brush.
5. A surgical guided stent was used so that the implant (Implantium, Dentium, Su-
won, Korea) was placed 2.0 mm subcrestal to the level of the adjacent bone in the
extraction socket.
6. A synthetic osteoconductive bone graft substitute composed of hydroxyapatite (HA)
and beta-Tricalcium phosphate (β-TCP) (Osteon III, Genoss, Suwon, Korea) and a
resorbable collagen membrane (Genoss, Suwon, Korea) were placed to cover the
implant and the peri-implant osseous defect.
7. After covering the bone graft with the collagen membrane, the extended IGT was
sutured with the palatal flap with 4-0 Catgut. Next, the buccal flap was closed using
4-0 nylon or black silk.
8. Antibiotics (Cefradine 500 mg, Yuhan Pharmaceutical Co., LTD. Seoul, Korea) and
anti-inflammatory drugs (Etodol® 200 mg, Yuhan Pharmaceutical Co., LTD. Seoul,
Korea) were prescribed for 10 days. The patient was recommended to use 0.12%
chlorhexidine solution (Hexamedine, Bukwang Pharmaceutical, Seoul, Korea) twice a
day for two weeks. Sutures were removed after 10 days.
9. Uncovering procedures were performed 4–6 months after initial surgery. Under local
anesthesia, the buccal flap was reflected, the regenerated tissue above the implant
cover screw was removed, and the healing abutment was connected to the implant.
The buccal flap was closed using 4-0 Catgut or black silk. Antibiotics and anti-
inflammatory drugs were prescribed for 5 days. The prosthesis was installed 2 months
after uncovering.

3. Case 1
Patient #1 was a 52-year-old non-smoker male with no systemic conditions affect-
ing the operation. The patient visited the clinic due to severe mobility of the maxillary
central incisor. This case is depicted in Figure 1. In the preoperative panoramic radio-
graph (Figure 1a), severe bone resorption was observed around the root of #21 with pe-
riapical radiolucency. In the CBCT cross-sectional view (Figure 1b), IGT was observed
around the root of #21. #21 had probing depths of more than 6 mm at all surfaces and
grade II tooth mobility. Extraction, immediate implant placement and GBR were performed
according to the described surgical protocol (Figure 1d–h). After extraction of #21, buccal
and palatal flaps were reflected and thorough defect debridement was performed. The IGT
attached to the buccal flap was dissected so that the base was attached to the existing flap
using a #15 blade, and the flap was extended (Figure 1d). The implant placed at #21 was
a 3.8 mm× 12 mm Implantium (Dentium, Suwon, Korea). A large peri-implant osseous
defect occurred after implant placement (Figure 1e). Bone graft substitute (Osteon III,
Genoss, Suwon, Korea) was placed to cover the implant (Figure 1f). A resorbable collagen
membrane (Genoss, Suwon, Korea) was placed over the graft and the extended IGT was
sutured with the palatal flap with resorbable sutures (Figure 1g). Primary closure was
achieved with the extended IGT (Figure 1h). A removable provisional restoration was
delivered 2 weeks after surgery. The GBR site healed well without any exposure (Figure 1i).
An uncovering procedure was performed 6 months after surgery with two submarginal ver-
tical incisions and buccal flap reflection. The observed regenerated tissue was very dense.
The final prosthesis was delivered 2 months after the uncovering procedure (Figure 1j).
In the panoramic radiograph and CBCT scan taken 12 months after the prosthesis was
delivered (Figure 1k–l), an adequate amount of new bone was observed on the labial surface
of the implant.
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Medicina 2022, 58, 1555 4 of 11

delivered (Figure 1k–l), an adequate amount of new bone was observed on the labial sur-
face of the implant.

Figure 1. Clinical and radiological findings of case #1. (a) Pre-operative panoramic radiograph
Figure 1. Clinical and radiological findings of case #1. (a) Pre-operative panoramic radiograph
showing severe bone resorption and periapical radiolucency around the root of #21 (white arrow).
showing severe bone
(b) Cross-sectional resorption
image of CBCTand periapical
#21 showingradiolucency
ICT around #21.around the root of #21
(c) Pre-operative (white arrow).
photograph #21.
(b)
(d) Cross-sectional
Flap extension by image of CBCT
dissection #21 ICT
of the showing ICT to
attached around #21. (c)
the buccal flapPre-operative
with the basephotograph
attached to#21.
the
(d) Flap extension
existing flap using by dissection
a #15 ofImplant
blade. (e) the ICT #21
attached to thewith
placement buccal flap with the
peri-implant base attached
osseous defect. (f)toBone
the
graft placement
existing flap usingover implant.
a #15 blade. (g)
(e) Resorbable
Implant #21collagen
placement membrane placementosseous
with peri-implant and extended IGT
defect. (f) su-
Bone
turedplacement
graft to the palatal
overflap with resorbable
implant. sutures.
(g) Resorbable (h) Primary
collagen closureplacement
membrane with extended IGT. (i) Post-
and extended IGT
operative
sutured tophotograph showing
the palatal flap no flap exposure.
with resorbable sutures.(j)(h)
Final prosthesis
Primary #21.with
closure (k) Panoramic
extended IGT.radiograph
(i) Post-
taken 12 months after prosthesis delivery. (l) Cross-sectional image of CBCT taken 12
operative photograph showing no flap exposure. (j) Final prosthesis #21. (k) Panoramic radiograph months after
prosthesis delivery with sufficient bone regenerated around the implant.
taken 12 months after prosthesis delivery. (l) Cross-sectional image of CBCT taken 12 months after
prosthesis delivery with sufficient bone regenerated around the implant.
4. Case 2
4. Case 2
Patient #2 was a 53-year-old non-smoker female with no systemic conditions affect-
ing the operation.
Patient #2 wasThe patient visited
a 53-year-old a private
non-smoker clinic
female seeking
with to replace
no systemic her recently
conditions ex-
affecting
tracted
the #23 implant.
operation. This case
The patient is depicted
visited a privateinclinic
Figure 2. Thetopreoperative
seeking panoramic
replace her recently radio-
extracted
graph
#23 and CBCT
implant. Thisscan
case showed severe
is depicted bone resorption
in Figure and IGT around
2. The preoperative the extracted
panoramic radiograph#23
implant
and CBCT socket. Implantsevere
scan showed placement and GBR were
bone resorption performed
and IGT around according to #23
the extracted the implant
surgical
socket. Implant placement and GBR were performed according to the surgical protocol as
described above. The GBR site healed well without exposure. An uncovering procedure
Medicina 2022, 58, x FOR PEER REVIEW 5 of 11
Medicina 2022, 58, 1555 5 of 11

protocol as described above. The GBR site healed well without exposure. An uncovering
was performed
procedure 6 months after
was performed the implant
6 months after thesurgery.
implant After tissue
surgery. punching,
After the healing
tissue punching, the
abutment was inserted and the final prosthesis was installed after 6 weeks. A
healing abutment was inserted and the final prosthesis was installed after 6 weeks.panoramic
A pan-
radiograph
oramic and CBCT
radiograph andscan
CBCT29 months
scan 29 after prosthesis
months delivery showed
after prosthesis deliverythat the marginal
showed that the
bone level was well maintained on implant #23.
marginal bone level was well maintained on implant #23.

Figure 2. Clinical and radiological findings of case #2. (a) Pre-operative panoramic radiograph
Clinical and radiological
Figure 2. compromised
showing findings
extraction socket #23.of(b)
case #2. (a) Pre-operative
Cross-sectional image ofpanoramic
CBCT #23radiograph
extraction
showing
socket compromised
showing extraction
loss of labial bonesocket #23. (b)
plate with ICT.Cross-sectional image
(c) Pre-operative of CBCT #23
photograph extraction
showing socket
extraction
showing
socket #23loss of labialprior
(extracted bone to
plate with ICT.
surgery). (d) (c)
FlapPre-operative
extension byphotograph
dissection ofshowing
the ICTextraction
attached socket
to the
buccal flap with the base attached to the existing flap after implant placement. (e) Bone
#23 (extracted prior to surgery). (d) Flap extension by dissection of the ICT attached to the buccal graft and
resorbable collagen membrane placement and extended IGT sutured to the palatal flap with
flap with the base attached to the existing flap after implant placement. (e) Bone graft and resorbable resorb-
able sutures
collagen with 4-0
membrane Catgut. (f)
placement andFlap closure
extended IGTwith extended
sutured to theIGT. (g) flap
palatal Post-operative photograph
with resorbable sutures
showing healing with no flap exposure and sufficient amount of keratinized gingiva. (h) Final pros-
with 4-0 Catgut. (f) Flap closure with extended IGT. (g) Post-operative photograph showing healing
thesis #23. (i) Cross-sectional image of CBCT taken 29 months after prosthesis delivery with suffi-
with no flap exposure and sufficient amount of keratinized gingiva. (h) Final prosthesis #23. (i) Cross-
cient bone regenerated around the implant.
sectional image of CBCT taken 29 months after prosthesis delivery with sufficient bone regenerated
around
5. Casethe3 implant.
5. Case 3
Patient #3 was a 72-year-old smoker male taking antihypertensive drugs and an-
tithrombotic
Patient #3drugs.
was This case is depicted
a 72-year-old smoker in male
Figure 3. Theantihypertensive
taking preoperative panoramic
drugs andradio-
an-
graph and CBCT scan showed severe bone resorption around the root of #13
tithrombotic drugs. This case is depicted in Figure 3. The preoperative panoramic radio- and IGT was
observed.
graph andClinical examshowed
CBCT scan showedsevere
a deepbone
probing depth and
resorption severe
around thetooth
rootmobility on #13.
of #13 and IGT
A
was3.8observed.
mm × 12 Clinical
mm Implantium
exam showedimplant (Dentium,
a deep probing Suwon, Korea)
depth and wastooth
severe placed in the ex-
mobility on
traction
#13. A 3.8socket
mm × of 12
#13,
mmandImplantium
surgery was performed
implant according
(Dentium, to the
Suwon, surgical
Korea) wasprotocol.
placed inThe
the
GBR site healed
extraction socket ofwell
#13,without exposure.
and surgery An uncovering
was performed according procedure was protocol.
to the surgical performedThe6
months
GBR siteafter surgery
healed and theexposure.
well without observed Anregenerated
uncoveringtissue was very
procedure was dense. The final
performed pros-
6 months
thesis was delivered
after surgery and the after 6 weeks.
observed In the tissue
regenerated panoramic radiograph
was very dense. Theand final
CBCT scan 35
prosthesis
months after prosthesis
was delivered delivery,
after 6 weeks. In thethe peri-implant
panoramic osseousand
radiograph defect
CBCTwasscan
well-regenerated.
35 months after
prosthesis delivery, the peri-implant osseous defect was well-regenerated.
Medicina 2022,
Medicina 58, x1555
2022, 58, FOR PEER REVIEW 6 6ofof 11
11

Figure 3. Clinical and radiological findings of case #3. (a) Pre-operative panoramic radiograph
Clinical
Figure 3.severe
showing boneand radiological
resorption findings
and IGT of #13.
around case (b)
#3.Mid-crestal
(a) Pre-operative
and twopanoramic radiograph
vertical incisions after
showing severe bone resorption and IGT around #13. (b) Mid-crestal and two vertical incisions
tooth extraction. (c) Implant #12 and #13 placement with peri-implant osseous defects. (d) Bone graft after
toothresorbable
and extraction.collagen
(c) Implant #12 and placement
membrane #13 placement
overwith peri-implant
implants. osseous
(e) Flap closuredefects. (d) Bone IGT.
with extended graft
(f)
and Post-operative photograph
resorbable collagen showing
membrane healing over
placement with implants.
no flap exposure.
(e) Flap(g) Final with
closure prosthesis #12 and
extended IGT.
#13. (h) Panoramic radiograph taken 35 months after prosthesis delivery. (i) Cross-sectional
(f) Post-operative photograph showing healing with no flap exposure. (g) Final prosthesis #12 and image
of
#13.CBCT taken 35 months
(h) Panoramic after taken
radiograph prosthesis delivery
35 months with
after sufficient
prosthesis bone regenerated
delivery. aroundimage
(i) Cross-sectional the im-
of
plant.
CBCT taken 35 months after prosthesis delivery with sufficient bone regenerated around the implant.

6.
6. Case
Case 44
Patient #4
Patient #4 was
was aa 76-year-old
76-year-old non-smoker
non-smoker female
female patient
patient with
with no systemic
systemic conditions
conditions
affecting the operation except for her rhinitis. The preoperative panoramic radiograph
affecting radiograph
and CBCT
and CBCT showed
showed severe bone resorption and IGT around existing #13 implant. After
implant. After
extraction of failing implant #13, a 3.8 mm × 12 mm Implantium implant
extraction of failing implant #13, a 3.8 mm × 12 mm Implantium implant (Dentium, (Dentium, Suwon,
Korea) was
Suwon, placed
Korea) (Figure(Figure
was placed 4). Bone4). graft
Bone and
graftcollagen membrane
and collagen membraneplacement and and
placement flap
closure
flap withwith
closure IGT IGT
extension werewere
extension performed according
performed to surgical
according protocol.
to surgical TheThe
protocol. GBRGBRsite
healed
site wellwell
healed without exposure.
without The The
exposure. uncovering procedure
uncovering was performed
procedure was performed6 months after
6 months
surgery.
after The regenerated
surgery. tissue tissue
The regenerated was very
washard.
very6hard.
weeks 6 after
weeks the uncovering
after procedure,
the uncovering the
proce-
final prosthesis was delivered. It was confirmed that all peri-implant osseous
dure, the final prosthesis was delivered. It was confirmed that all peri-implant osseous defects were
regenerated
defects were in the panoramic
regenerated in theradiograph and CBCT scan
panoramic radiograph 28 months
and CBCT scan after the prosthesis
28 months after the
was delivered.
prosthesis was delivered.
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Figure 4. Clinical and radiological findings of case #4. (a) Pre-operative panoramic radiograph
Figure 4. Clinical and radiological findings of case #4. (a) Pre-operative panoramic radiograph show-
showing severe bone resorption and periapical radiolucency around the existing implant #13. (b)
ing severe boneimage
Cross-sectional resorption and#13
of CBCT periapical
showingradiolucency
ICT. (c) Flap around
extensiontheby
existing implant
dissection of the#13.
ICT(b) Cross-
attached
sectional image of CBCT #13 showing ICT. (c) Flap extension by dissection of the ICT attached
to the buccal flap with the base attached to the existing flap using a #15 blade. (d) Implant #13 place- to the
buccalwith
ment flapperi-implant
with the base attached
osseous to the
defect. (e)existing
Bone graftflapand
using a #15 blade.
resorbable (d) Implant
collagen membrane#13 placement
placement
over
with implant. Extended
peri-implant osseous IGT sutured
defect. to palatal
(e) Bone flap.resorbable
graft and (f) Flap closure with
collagen extendedplacement
membrane IGT. (g) Post-
over
operative photograph
implant. Extended IGTshowing healing
sutured to palatalwith
flap.no(f)flap
Flapexposure. (h) Panoramic
closure with extended IGT. radiograph taken 28
(g) Post-operative
months aftershowing
photograph prosthesis delivery.
healing with(i)noCross-sectional
flap exposure. image of CBCTradiograph
(h) Panoramic taken 28 months
taken after prosthesis
28 months after
delivery
prosthesiswith sufficient
delivery. bone regenerated
(i) Cross-sectional image around
of CBCTthe implant.
taken 28 months after prosthesis delivery with
sufficient bone regenerated around the implant.
7. Case 5
7. Case 5 #5 was a 54-year-old smoker male with had severe bone resorption around
Patient
Patient5).
#36 (Figure #5Extraction,
was a 54-year-old
implant smoker male
placement andwith had severeGBR
simultaneous bonewere
resorption around
performed ac-
#36 (Figure
cording 5). surgical
to the Extraction, implant
protocol. Theplacement and simultaneous
GBR site healed GBR were
without exposure and theperformed
location
according
of to the surgical
the mucogingival protocol.
junction The unchanged.
was also GBR site healed
Afterwithout exposure
5 months, and the location
an uncovering proce-
of thewas
dure mucogingival
confirmedjunction was
that new also was
bone unchanged. After at
well formed 5 months,
the GBR ansite.
uncovering procedure
In the panoramic
was confirmed
radiograph 19 that new after
months bone prosthesis
was well formed at the GBR
placement, theresite.
wasInnothechange
panoramic radiograph
in crestal bone
19 months after prosthesis
level around the implant. placement, there was no change in crestal bone level around
the implant.
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Figure 5. Clinical and radiological findings of case #5. (a) Pre-operative panoramic radiograph
Figure 5. Clinical and radiological findings of case #5. (a) Pre-operative panoramic radiograph
showing severe bone resorption around #36. (b) Flap extension by dissection of the ICT attached to
showing
the buccalsevere bonethe
flap with resorption around
base attached to #36. (b) Flapflap.
the existing extension by graft
(c) Bone dissection of theover
placement ICT attached to
#36 implant.
the Flap
(d) buccal flap with
closure withtheextended
base attached
IGT. to(e)the existing flap. photograph
Post-operative (c) Bone graftshowing
placement over #36
healing implant.
with no flap
(d) Flap closure
exposure. with extended
(f) Panoramic IGT. taken
radiograph (e) Post-operative photograph
19 months after prosthesisshowing healing with no flap
delivery.
exposure. (f) Panoramic radiograph taken 19 months after prosthesis delivery.
8. Case 6
8. Case 6
Patient #6 was a 72-year-old non-smoker female who visited the clinic for implant
Patient #6 was a 72-year-old non-smoker female who visited the clinic for implant
placement in the left posterior mandible (Figure 6). The preoperative panoramic radio-
placement in the left posterior mandible (Figure 6). The preoperative panoramic radio-
graph
graph showed severe
showed bone resorption
severe bone resorption around
aroundteeth
teeth#35
#35and
and#36.
#36.Implants
Implantswere
wereplaced
placedinin
compromised sockets after extractions of #35 and #36, and peri-implant osseous
compromised sockets after extractions of #35 and #36, and peri-implant osseous defects defects
were
were treated according to
treated according to the
the surgical
surgical protocol.
protocol.The TheGBR
GBRsites
siteswere
werenot
notexposed
exposedand andthe
the
location of the mucogingival junction was not changed. After 4 months,
location of the mucogingival junction was not changed. After 4 months, an uncovering an uncovering
procedure
procedure was was performed
performedandanditit was
wasobserved
observedthat thatthe
thebone
bonedefects
defectswere
werefilled
filledwith
withdense
dense
bone. 26 months after the delivery of the final prosthesis, there was no change
bone. 26 months after the delivery of the final prosthesis, there was no change in crestal in crestal
bone
bone level
level around implant
implant #35.
#35.
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Figure 6. Clinical and radiological findings of case #6. (a) Pre-operative panoramic radiograph
Figure 6. Clinical and radiological findings of case #6. (a) Pre-operative panoramic radiograph
showing severe bone resorption around #35 and 36. (b) Compromised sockets #35, 36. (c) #35, 36
showing severe bone
implant placement resorption
with around
peri-implant #35 and
osseous 36. Flap
defect. (b) Compromised sockets #35,
extension by dissection of 36.
the (c)
ICT#35,
at-
36 implant
tached placement
to the buccal flap with peri-implant
with osseous
the base attached to defect. Flap flap.
the existing extension by dissection
Bone graft placementof over
the ICT
#36
attached
implant. to
(d)the buccal
Flap flapwith
closure withextended
the base attached
IGT. (e) to the existing flap.
Post-operative Bone graft
photograph placement
showing overwith
healing #36
no flap exposure.
implant. (f) Panoramic
(d) Flap closure radiograph
with extended IGT. taken 26 months after
(e) Post-operative prosthesis
photograph delivery.
showing healing with no
flap exposure. (f) Panoramic radiograph taken 26 months after prosthesis delivery.
9. Discussion
9. Discussion
In the case of a tooth or implant with severe infection, infectious granulation tissue
In theThis
is formed. caseIGTof awas
tooth or implant
referred to as with severe infection,
“intrasocket infectious
reactive soft tissue” ingranulation tissue
previous studies
is formed.
[7,8] and thisThis IGT was referred
granulation tissue wasto asremoved
“intrasocket
during reactive
socketsoft tissue” in previous
preservation or socket stud-
aug-
ies [7,8] and this granulation tissue was removed during socket
mentation because it contains many inflammatory cells and long junctional epithelium preservation or socket
augmentation because it et
[8]. However, Mardinger contains many
al. [8] and Hurinflammatory cells and
et al. [9] suggested that long junctional
IGT can epithe-
play a positive
lium [8]. However, Mardinger et al. [8] and Hur et al. [9] suggested that IGT can play
role in GBR procedures. This case series demonstrated that primary closure can be
a positive role in GBR procedures. This case series demonstrated that primary closure
achieved by extending the flap through dissection of IGT after immediate implant place-
can be achieved by extending the flap through dissection of IGT after immediate implant
ment in a compromised extraction socket. The wound edges of all cases were well closed
placement in a compromised extraction socket. The wound edges of all cases were well
without membrane exposure even though periosteal releasing incisions were not per-
closed without membrane exposure even though periosteal releasing incisions were not
formed. In addition, this procedure resulted in little shift in the location of the mucogingi-
performed. In addition, this procedure resulted in little shift in the location of the mucogin-
val junction, and there were no severe post-operative complications. Sufficient bone re-
gival junction, and there were no severe post-operative complications. Sufficient bone
generation at the surgical sites was also well observed.
regeneration at the surgical sites was also well observed.
Compared to extraction sockets of uncompromised teeth, compromised extraction
Compared to extraction sockets of uncompromised teeth, compromised extraction sockets
sockets have larger bone defects and more granulation and inflammatory tissues. Kim et
have larger bone defects and more granulation and inflammatory tissues. Kim et al. [6] stated
al. [6]
that stated
it is that ittoiscompletely
important important to completely
remove remove
the infection the infection
source source
during ridge during ridge
preservation in
preservation in a compromised extraction socket. Ridge augmentation
a compromised extraction socket. Ridge augmentation after sufficient soft tissue healing after sufficient soft
tissue
or healing
delayed or delayed
implant implant
placement afterplacement after ridgeare
ridge preservation preservation are common
common techniques thattech-
can
niques that can be applied in cases of compromised sockets [6,8–10].
be applied in cases of compromised sockets [6,8–10]. However, natural, non-intervened However, natural,
non-intervened
healing healing of
after extraction after extraction ofcompromised
periodontally periodontallyteeth compromised teeth loss
leads to severe leads ofto se-
both
vere loss of both soft and hard tissues. According to a systematic review
soft and hard tissues. According to a systematic review by Tan et al. [11], after tooth by Tan et al. [11],
after tooth there
extraction, extraction,
is rapidthere
lossisofrapid lossbone
alveolar of alveolar bone3–6
in the first in months
the first and
3–6 months
gradual and grad-
reduction
ual reduction
thereafter. thereafter.
Therefore, Therefore,
delayed implant delayed implant
placement placement
performed afterperformed
healing may afterrequire
healing a
may require
large amountaof large
GBR. amount
Estheticof problems
GBR. Esthetic
mayproblems
also occurmay afteralso occurwith
surgery aftersoft
surgery with
and hard
soft and
tissue hard tissue
deficiencies deficiencies
especially in the especially in theInesthetic
esthetic area. area. the
this respect, In this respect,combining
treatment the treat-
immediate implant placement and simultaneous GBR can have many advantages. many
ment combining immediate implant placement and simultaneous GBR can have
advantages.
Maintaining a tension-free flap for primary closure is a critical factor for the success of
a GBR Maintaining
procedure.aFugazzotto
tension-free[12] flapsuggested
for primary thatclosure
membraneis a critical
exposurefactor for the success
occurring within
of a GBR procedure. Fugazzotto [12] suggested that membrane exposure occurring within
Medicina 2022, 58, 1555 10 of 11

6 months after GBR therapy is considered a failure. Membrane exposure can increase the
risk of infection and damage to bone formation [13]. However, there are studies that show
that bone regeneration is not affected even with an open wound, and there are techniques
such as the open membrane technique to intentionally expose the GBR technique [14–16].
The low porosity of the d-PTFE (dense polytetrafluroethylene) membrane is resistant to
bacterial infiltration, reducing exposure problems [17]. On the other hand, the resorbable
collagen membrane is continuously absorbed and incorporated into the host tissue. There-
fore, it is expected that there will be little or no adverse effects from membrane exposure of
a collagen membrane [18,19]. However, according to the authors’ experience and several
reports, it is true that the exposure of the wound edge can have a high risk of infection and
insufficient bone regeneration [13,20]. Sbricoli et al. [21] stated that in clinical practice, the
healing process after application of the collagen membrane is uneventful, but the observa-
tion of membrane exposure is not uncommon; in addition, they described that when the
membrane was exposed to the oral environment, it had a high risk of bacterial colonization,
resulting in faster degradation and ultimately resulting in severely reduced regeneration.
Therefore, several surgical techniques have been introduced to enhance the closure of the
flaps. Commonly used methods include periosteal releasing incisions, horizontal mattress
sutures, double flap incision, and addition of a subepithelial connective tissue graft [22–25].
These techniques can lead to postoperative complications such as bleeding, swelling, and
hematomas and may require additional treatment related to this [26,27].
In the reported cases, although periosteal releasing incisions were not performed to
help with primary wound closure, early wound exposures did not occur because of the
utilization of the IGT that can provide additional soft tissue support. Furthermore, there
was no intentional flap advancement, so there was no change in vestibular depth and no
loss of keratinized gingiva. This technique is suitable for a compromised socket with a
IGT that is thick (more than 2 mm) and wide. If the IGT is thin, it is more likely to be
damaged during incision and dissection for flap extension. Therefore, this procedure is
suitable to be performed in a compromised extraction socket with more severe bone defects.
However, one must be cautious about the interpretation of the described technique. The
definition of granulation tissue is histological and, from a clinical point of view, one could
only assume to cut exactly between the granulation tissue and the flap, thus, from time to
time, a unintentional semi-split-thickness flap may occur. The disadvantage of this case
report is its limited patient pool. A study on the clinical effect and validity of the procedure
will be needed in the future.

10. Conclusions
Within the limitations of this case series, the IGT of compromised extraction sockets
is potentially useful for primary closure of the wound when performing GBR surgery
concurrently with immediate implant placement.

Author Contributions: Conceptualization, W.-B.P. and P.K.; Methodology, W.-B.P.; Validation, W.-B.P.,
P.K. and J.-Y.H.; Formal analysis, W.-B.P., J.-Y.H. and P.K; Investigation, W.-B.P. and J.-M.K.; data
curation, W.-B.P.; writing—original draft preparation, W.-B.P., J.-M.K. and P.K.; Writing—review and
editing, P.K. and J.-M.K.; Visualization, W.-B.P. and J.-M.K.; Supervision, W.-B.P.; Project administra-
tion, W.-B.P. and P.K. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: No applicable.
Informed Consent Statement: Written informed consent has been obtained from all patients to
publish this paper.
Data Availability Statement: All data is contained within the article.
Conflicts of Interest: The authors declare no conflict of interest.
Medicina 2022, 58, 1555 11 of 11

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