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Importance of the vestibular cortex in anterior maxillary teeth
Introduction
Post-extraction alveolar changes have been analysed in experimental (1) and clinical (2) studies and published in the literature. The vestibular cortex is the structure in the alveolar process that is most susceptible to bone remodelling after tooth extraction, and this reabsorption depends largely on the anatomy and width of the pre-existing vestibular cortex. Studying and analysing this anatomical structure is therefore of great interest to help predict the dimensional changes of the socket after extraction.
Vestibular cortex measurement methods
The vestibular cortex is a structure that is difficult to evaluate due to its reduced width and requires extremely precise and accurate measurement methods. The method of analysis of the vestibular cortex endorsed by the greatest number of scientific publications is cone-beam computed tomography (CBCT) (3). It is a non-invasive, high-resolution, low-dose radiation method that provides a complete image of the alveolar bone (4) (Figure 1).
Other methods described in the literature for measuring the vestibular cortex are probing (5) and ultrasound (6). The main objective of the analysis of the gauge of the vestibular cortex is diagnosis and planning prior to surgery, and measurement by probing is an invasive method that requires tooth extraction in order to perform the measurements (7) (Figure 2). Ultrasound has shown great potential in both the measurement of the vestibular cortex in teeth (8) and in implants (9), but to date most studies are in vitro and on cadavers, and further clinical studies would be needed to sanction its use.
Thickness of the vestibular cortex
The thickness of the vestibular cortex in the anterior maxillary teeth is scant, usually between 0.5-1 mm (10) and very often presenting some kind of bone defect. A study of the teeth in 4319 cadavers determined that only 25% presented an intact vestibular cortex (11) (Figure 3). It has also been described that in posterior teeth, including premolars and molars, this vestibular cortex is larger, on average between 1-2 mm.
There are several factors that lead us to suspect whether the vestibular cortex will be wide or narrow, even before performing CBCT. Women, patients over 50, and patients with a thin gingival biotype have shown a significantly narrower vestibular cortex in the maxillary teeth (12 – 14), just as Asian patients tend to show a narrower vestibular cortex than Europeans and Americans. Another factor that has been shown to influence the gauge of this cortex is the distance from the cementoenamel junction (CEJ) to the vestibular ridge; patients with loss of attachment who have a greater than physiological CEJ-to-ridge distance (1-3 mm) tend to present a narrower vestibular cortex.
Vestibular cortical phenotype
The vestibular cortical phenotype was classified in 2013 by Mandelaris (15) as thick when the cortex was ≥1 mm, and thin when it was <1 mm. In a prospective clinical study in 39 patients (16), a different reabsorption pattern was observed according to the phenotype of the vestibular cortex. In alveoli with a thin vestibular cortical phenotype, there was an average vertical bone loss of 7.5 mm at 8 weeks after extraction, i.e. 62% of the initial vestibular bone height. In contrast, patients with a thick phenotype showed an average vertical bone loss of only 1.1 mm or 9%. The pattern of dimensional alteration in single-tooth extraction areas with healthy surrounding dentition occurred mainly in the central area of the alveolar wall, while the proximal areas remained almost unchanged after flapless tooth extraction with 8 weeks of healing (16).
Preservation of the alveolar ridge
Ridge preservation is a guided bone regeneration technique that aims to minimise volumetric changes in hard and soft tissues after tooth extraction (17). This is a well-documented technique that shows benefits in maintaining bone ridge dimensions in comparison with spontaneous alveolar healing (18).
Although it maintains the dimensions of the alveolar ridge, the inner portion of the alveolar walls formed by fascicular bone and the thin vestibular cortices will inevitably be reabsorbed after exodontia (19). Spinato et al. (20) observed that ridge preservation in the alveoli with a thicker vestibular cortex (> 1 mm) produced a horizontal reduction of 1.29 ± 0.2 mm, while the horizontal reduction in the thinner cortical alveoli (<1 mm) was 3.22 ± 0.2 mm.
Time of implant placement depending on the vestibular cortex
Evaluation of the vestibular cortex width provides the clinician with a prognostic tool to estimate the degree of future bone loss prior to tooth extraction (21). Oral bone resorption after extraction differs between studies, individuals and location of the tooth to be extracted. Factors involved in this variation include the presence or absence of infection, flap versus flapless extraction, the degree of trauma during exodontia, and the thickness of the vestibular cortex before extraction (7).
The placement of immediate implants after extraction is a technique that decreases morbidity and shortens the time before replacing the tooth lost (22). This technique is recommended in ideal clinical conditions for a thick vestibular cortical phenotype (> 1 mm) and a thick gingival biotype (21) (Figure 4). A recent prospective study (23) of immediate implants with immediate provisionalisation showed that in the following year there was resorption of the vestibular cortex of the implant and recession of the soft tissues when the gauge of the vestibular cortex after exodontia was <0.5 mm, and that when the vestibular cortex was thicker the hard and soft tissues of the implants remained stable.
Conclusions
Analysis of the anatomy of the vestibular cortex in the anterior maxillary sector with CBCT provides the clinician with a prognostic tool to estimate the degree of future bone loss before tooth extraction. In women, those over 50, thin gingival biotypes and Asians, a narrower gauge of the vestibular cortex is to be expected, and thus the dimensional changes after exodontia will be greater.
About the Author
Julio Rojo Sanchis. Associate Professor at the University of Valencia. Member of the Spanish Society of Oral Surgery.
José Viña Almunia. Associate Professor at the University of Valencia. Member of the Spanish Society of Oral Surgery.
Bibliography
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Figure 1. CBCT of an upper central incisor in the sagittal plane where the width of the vestibular cortex can be measured. In this case we see that the root is in close contact with a vestibular cortex quite uniform in width along its entire apical-coronal dimension.
Figure 2. Measurement of the vestibular cortex after extraction of an upper premolar, lifting a flap using calipers.
Figure 3. When lifting the full thickness of a flap in the anterior maxillary sector, 2.3 canine presents bone fenestration.
Figure 4. In a patient with a thick vestibular cortical phenotype, with a cortical width of about 2 mm, no great resorption of the alveolar ridge is to be expected, and so this would be a case for placing an immediate implant.
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