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The ARP Techniques in Dentistry

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Dental surgeons commonly recommend these current concepts of ARP for prosthetic reasons. Read the article to know more about it.

Written byDr. Achanta Krishna Swaroop

Medically reviewed byDr. Lekshmipriya. B

Published At April 19, 2022
Reviewed AtOctober 18, 2024

What Is ARP?

ARP (alveolar ridge preservation) is a method adopted by dental surgeons. ARP is defined as the procedure of arresting or minimizing the alveolar ridge resorption following tooth extraction for future prosthodontic treatment, including placement of dental implants.

What Is the Alveolar Process?

The alveolar process is one of the most important anatomical structures that plays a significant role in implant placement. The alveolar process is a structure that holds tooth sockets (dental alveoli) and is present as a thick ridge of the bone under the tooth socket. The dental alveoli hold the teeth' roots in place and act as support in the future during implant placement after the tooth is removed or missing. There are two types of the alveolar process: the alveolar process of the maxilla, which is under the maxillary sinus, and the alveolar process of the mandible, which is just above the mandible or jawbone. During tooth removal, 30 to 60 percent of the bone in the alveolar process may be lost. In such cases, the alveolar preservation technique is used for implant placement.

The bone height and physiology are constantly reduced by resorption following a tooth extraction, which is maintained predictably, preventing the ridge from further resorption and maintaining bone volume and height. The techniques of ARP mainly revolve around the usage of guided bone regeneration material (GBR), growth factors, certain socket sealers, and fillers, all of which can aid in healthy bone preservation and remodeling process despite the tooth being removed for whatever reasons (periodontal damage, mobility, gross decay or non-vitality).

What Is Alveolar Ridge Preservation in the Esthetic Zone?

For implant procedures, the treatment plan is formulated well before teeth extraction. This is done to prevent bone and soft tissue changes before extraction. Either the extraction site should heal naturally, the implant should be placed immediately after extraction, or techniques like ARP should be done to preserve bone loss during tooth removal. The following factors are considered before treatment planning for tooth extraction:

  1. The time when the implant is placed.
  2. Soft tissue quality and quantity in the extraction socket.
  3. Remaining bone height in the buccal area (outer gum area).
  4. Prognosis of the implant procedure.

According to studies, three types of healing periods are allowed that comprises:

  • Soft tissue preservation with six to eight weeks of healing after tooth removal. This is done to optimize the soft tissues.
  • Hard and soft tissue must be preserved within four to six months of healing after tooth extraction. This is done to optimize both hard and soft tissues.
  • Hard tissue preservation for more than six months after tooth removal. This is done to optimize the hard tissues.

What Is the Need for ARP Techniques?

Patients should choose ARP before prosthetic implantation of the missing tooth or even in severely edentulous cases for wearing dentures because post-tooth extraction, the bundle bone (the bone that lines the alveolar socket and encloses periodontal or Sharpey's fibers for tooth support in the jaw) is absorbed almost immediately. In contrast, the jaw's alveolar bone takes time to resorbed. However, once it starts being resorbed, the vertical height of the tooth socket and the bony contour are slowly lost over time.

ARP technique mainly helps prevent this reduction in height and contour over time, and this is a boon clinically to improve prosthetic outcomes successfully in patients post extraction of tooth or teeth. This progressive and irreversible phenomenon can give rise to esthetic, functional, and prosthodontic challenges and interfere with ideal implant placement for tooth replacement therapy. Several therapeutic attempts have been employed to minimize post-extraction ridge atrophy (loss of alveolar bone after post-tooth removal), a concept defined as alveolar ridge preservation (ARP).

Bone remodeling is almost always negatively impacted post a tooth extraction left unattended by a prosthesis like an implant, crown, or bridge for a long period. This is mainly because the esthetics, the contour, and the height of the alveolar ridge may often be hindered by unfavorable resorptive processes. Hence, ARP follows the current trend of bone conservation, height or bony contour and shape preservation, and the alveolar ridge to preserve the natural tissue. The need for ARP before prosthetic replacement is also due to the soft tissue and periodontal ligament, which are major sources of vascular strength for the socket wall of the tooth, which are also severed when a tooth is extracted.

What Are the Current Concepts in ARP?

Several studies have also adopted the concept of guided bone regeneration (GBR), utilizing a barrier membrane to prevent soft tissue ingrowth and encapsulation of the graft particles to promote bone formation. Other methods for ARP have involved flap procedures in minimizing the surgical trauma, under the assumption that this would facilitate greater bone gain. Combinations of membrane grafting alongside bone grafting are tested procedures in the research documentation, and the success rates of prosthetic replacements after ARP procedures are high.

Bone grafting histologically, as research, even after six months of placement and eventual healing within the socket (used to augment, contour, and maintain the ridge height), usually shows no major changes either in horizontal or vertical dimensions if allografts (tissue transplantation from one person to another person) or xenografts (tissue transplantation from one person to another species) are used. However, with the advancement in bone grafting, newer age alloplastic materials such as tricalcium phosphate crystals and bioactive polymers (glass polymers) are a few examples of showing both horizontal and vertical bone height changes, making the site suitable for dental implantation.

Many factors that could have influenced the pattern of ridge resorption (single versus multiple-rooted teeth, grafting material, a reflection of a flap, or obtaining primary wound closure) are assessed through meta-regression analyses to determine their significance. The current clinical research results indicate significantly less horizontal and mid-buccal vertical bone loss when the reflection of flaps was avoided during the surgical procedure. This analysis is further highlighted when analyzed for obtaining primary wound closure.

What Are the Studies That Prove ARP Reduces Bone Resorption?

In various research analyses, the changes in the outcome measures (alveolar ridge dimensions) have been assessed clinically or with standardization to ensure reliability in reporting. Clinical procedures (grafting material, application and type of membrane used, whether flap was raised, if primary wound closure was achieved, the allocated time or healing). Meta-analysis confirms the effectiveness of ARP in reducing ridge loss in all the investigated outcomes compared to unassisted healing of extraction sockets. In these clinical observations, the potential studies must have contained at least a test and a control group, comparing post-extraction ARP via socket grafting to unassisted natural healing in non-compromised intact extraction sockets, allowing at least three months for the healing process.

Conclusion

ARP procedures are being successfully adopted and used in modern-day clinical practice, along with atraumatic extraction procedures. Then, bone graft substitutes to increase or maintain bone volume and height have been proven to reduce but not eliminate the physiological cascade of post-extraction bone remodeling. Knowledge of these techniques may help clinicians and patients plan for implants during tooth extraction.

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Frequently Asked Questions

Alveolar preservation strategies have been shown to minimize the ridge volume loss that normally occurs after tooth extraction. Ridge preservation, also called socket preservation, is a procedure in which dentists use bone grafting materials to prevent loss of bone structure and protect the alveolar ridge after tooth extraction. Losing teeth can be accompanied by the subsequent loss of bone structure, making it impossible to receive dental implants in the future. However, jaw retention prevents the loss of jawbone structure and keeps options open.
By placing grafting materials, doctors create a framework for new bone growth and use the material's physical properties to maintain the space to prevent bone plate collapse and potential soft-tissue infiltration.
To preserve a ridge or graft a socket, the following protocol is followed:
 
 1. Atraumatic extraction of the tooth.
 2. Thorough cleaning of the socket.
 3. Placement of the graft material.
 4. Contain the graft material in the socket with sutures.
 5. Allow 4 to 6 months for healing, depending upon the graft material used.
The alveolar ridge is an extension of the maxilla (upper jaw) and mandible (lower jaw) and is the bony ridge that holds the alveolar sockets. The alveolar ridge is an anatomical structure critical to healthy teeth and successful dental implants. Loss of alveolar ridge height can prevent a person from getting implants or any other prosthesis in the mouth.
The alveolar bone is an essential tissue for tooth retention. However, once the alveolar bone is lost, it cannot be regenerated naturally. Bone grafts and artificial bones are commonly used for alveolar bone regeneration. Alveolar bone height is very critical to the placement of the prosthesis.
The supporting alveolar bone structure is composed of both cortical and cancellous bone. Cortical bone, also called a cortical plate, consists of compact bony plates found on the facial and lingual surfaces of the alveolar bone. The alveolar bone is made up of ridges that support the teeth. The root of the tooth is located in a deep depression, the alveolar cavity of the bone. Alveolar bone develops during tooth eruption and atrophies after tooth loss. It readily reacts to external and systemic influences. The usual response to stimuli is absorption, but in some situations, it can be accompanied by deposition.
In addition to connecting the tooth to the jawbone, the alveolar process is important for tooth alignment and periodontal ligament (PDL) function. Due to its unique composition, the alveolar process can withstand the forces exerted on the mouth by mastication. The support of the alveolar process is vital to the chewing action.
There are two main types of bone loss patterns seen in the alveolar bone: horizontal bone loss and vertical bone loss. Horizontal bone loss is reflected in moderately even bone loss, resulting in an even reduction in bone height relative to the tooth. Vertical bone loss is defined as the resorption of at least 2 mm of interdental bone with a typical angulation.
The Socket Shield Technique involves the bisection of the root and holds the buccal two-thirds of the root in the socket, leaving the tissues of the socket intact along with the bone. This technique shows promising post-extraction socket preservation results and great implant placement value.
Socket preservation, or alveolar ridge preservation, is a procedure to reduce bone loss after tooth extraction. After tooth extraction, the jawbone naturally narrows and loses its original shape due to rapid bone resorption. Socket preservation is an attempt to prevent bone loss by placing a bone graft in a socket immediately after tooth extraction. During the procedure, the gums are pulled back; the tooth is removed, a bone graft is placed in the tooth socket, it is covered with a barrier membrane, and it is stitched.
The alveolar process also has supporting bones with the same components, including Fibers, cells, intercellular substances, nerves, blood vessels, and lymphatics. The alveolar process is the lining inside the tooth socket and is called the alveolus. Alveolar bone can be divided into two main parts: a thin layer of dense bone and then a less dense bone beneath it.
The alveolar ridge, also called the alveolar margin, is one of the two maxillary ridge extensions of the lower or upper jaw, located on the palate between the upper teeth and the hard palate or at the base of the mouth behind the lower teeth. Most of the palate consists of hard and soft palates. The alveolar ridge contains the tooth cavity. It can be felt with the tongue in the area just above the upper teeth or under the lower teeth, the surface of which is covered with small ridges.
The alveolar bone is associated with or forms the part of the jaw from which the teeth arise. The word alveolar also refers to the air-containing compartments of the lungs or glands with secretory cells around the central space. This air-containing property of the alveolar bone type gives it the name alveolar.
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Dr. Achanta Krishna Swaroop from iCliniq
Dr. Achanta Krishna Swaroop

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