A RS of Post-Extractional Alveolar Hard and Soft Tissue Dimensional Changes

Wah Lay Tan
Terry L. T. Wong
May C. M. Wong
Niklaus P. Lang
Authors affiliations:
Wah Lay Tan, Terry L. T. Wong, May C. M. Wong,
Niklaus P. Lang, Implant Dentistry, The University
of Hong Kong, Prince Philip Dental Hospital,
Implant Dentistry, Hong Kong, China
Corresponding author:
Prof. Niklaus P. Lang, DMD, MS, PhD, Dr odont.h.
c. mult.
The University of Hong Kong Faculty of Dentistry
Prince Philip Dental Hospital
34 Hospital Road, Sai Ying Pun
Hong Kong, China
Tel.:+852 2859 0526
Fax: +852 2858 6114
e-mail: nplang@dial.eunet.ch
A systematic review of post-extractional alveolar hard and soft tissue

dimensional changes in humans
Key words: alveolar bone, dimensional change, extraction, hard tissue, human, removal of
teeth, resorption, soft tissue, systematic review

Abstract
Background: Removal of teeth results in both horizontal and vertical changes of hard and soft
tissue dimensions. The magnitude of these changes is important for decision-making and
comprehensive treatment planning, with provisions for possible solutions to expected
complications during prosthetic rehabilitation.
Objectives: To review all English dental literature to assess the magnitude of dimensional changes
of both the hard and soft tissues of the alveolar ridge up to 12 months following tooth extraction
in humans.
Methods: An electronic MEDLINE and CENTRAL search complemented by manual searching was
conducted to identify randomized controlled clinical trials and prospective cohort studies on hard
Conflicts of interest
The authors declare no conflict of interest.
and soft tissue dimensional changes after tooth extraction. Only studies reporting on undisturbed
post-extraction dimensional changes relative to a fixed reference point over a clearly stated time
period were included. Assessment of the identified studies and data extraction was performed
independently by two reviewers. Data collected were reported by descriptive methods. Weighted
means and percentages of the dimensional changes over time were calculated where appropriate.
Results: The search provided 3954 titles and 238 abstracts. Full text analysis was performed for 104
articles resulting in 20 studies that met the inclusion criteria. In human hard tissue, horizontal
dimensional reduction (3.79 0.23 mm) was more than vertical reduction (1.24 0.11 mm on
buccal, 0.84 0.62 mm on mesial and 0.80 0.71 mm on distal sites) at 6 months. Percentage
vertical dimensional change was 1122% at 6 months. Percentage horizontal dimensional change
was 32% at 3 months, and 2963% at 67 months. Soft tissue changes demonstrated 0.40.5 mm
gain of thickness at 6 months on the buccal and lingual aspects. Horizontal dimensional changes of
hard and soft tissue (loss of 0.16.1 mm) was more substantial than vertical change (loss 0.9 mm to
gain 0.4 mm) during observation periods of up to 12 months, when study casts were utilized as a
means of documenting the changes.
Conclusions: Human re-entry studies showed horizontal bone loss of 2963% and vertical bone
loss of 1122% after 6 months following tooth extraction. These studies demonstrated rapid
reductions in the first 36 months that was followed by gradual reductions in dimensions
thereafter.
Date:
Accepted 15 October 2011
To cite this article:

Tan WL, Wong TLT, Wong MCM, Lang NP. A systematic
review of post-extractional alveolar hard and soft tissue
dimensional changes in humans.
Clin. Oral. Impl. Res. 23(Suppl. 5), 2012, 121
doi: 10.1111/j.1600-0501.2011.02375.x
2011 John Wiley & Sons A/S
The periodontium is an important structure

that supports the tooth and is affected by any
changes that the tooth may undergo, including eruption and extraction (Cohn 1966; Pietrokovski & Massler 1967, 1971). The
alveolar process is a tooth-dependent tissue;
the shape and volume of the alveolar process
is influenced by tooth form, as well as the
direction of eruption of the tooth (Marks
1995; Marks & Schroeder 1996), and the presence or absence of teeth (Tallgren 1972). Similarly, gingival tissues undergo changes
together with eruption and eventual exfolia-
tion or extraction of the tooth. Subsequent to

removal of a tooth, the periodontium undergoes atrophy (Cohn 1966; Schropp et al.
2003), with the complete loss of attachment
apparatus including cementum, periodontal
ligament fibres and bundle bone (Araujo &
Lindhe 2005).
Tooth extraction is one of the most widely
performed dental procedures. In general, postextraction healing of both the hard and soft
tissues proceeds uneventfully. However, the
removal of a tooth will generally result in
some alveolar bone loss, as well as structural
Tan et al Dimensional tissue changes post extraction
and compositional changes in the overlying

soft tissue (Schropp et al. 2003). Both horizontal and vertical changes in dimensions are
expected in hard tissue (Van der Weijden
et al. 2009) as well as soft tissue. Studies in
the canine model (Araujo & Lindhe 2005;
Araujo et al. 2005) have demonstrated that
there are marked dimensional changes of the
alveolar ridge in the first 23 months postextraction, with the changes more pronounced on the buccal (Araujo et al. 2005).
Critically, horizontal buccal bone resorption
has been shown reach as much as 56% while
lingual bone resorption has been reported to
be up to 30% (Botticelli et al. 2004); the overall reduction in width of the horizontal ridge
has been reported to reach 50% (Schropp
et al. 2003).
A narrower and shorter ridge can be an
expected sequelae of the resorptive process
(Pinho et al. 2006), and in effect, the process
of resorption often results in the relocation of
the ridge to a more lingual position (Botticelli
et al. 2004). The process of ridge remodelling
is further complicated if the buccal bone wall
is lost (Iasella et al. 2003) as a result of
inflammatory processes or the extraction
itself.
Extraction of one or more teeth results
not only in changes of the bony architecture, but also affects the overlying soft tissues of the alveolus (Schropp et al. 2003).
Immediately following tooth extraction,
there is absence of soft tissue covering over
the socket entrance, and hence the socket
defect is left to heal by secondary intention.
In the subsequent weeks, cell proliferation
will result in an increase in soft tissue volume, and a soft tissue covering will seal the
socket entrance. The changes in the mucosal contours are dependent on the corresponding changes in the external profile of
the alveolar bone surrounding the extraction
site.
The magnitude of these dimensional
changes are important for informed decisionmaking and comprehensive treatment planning, with provisions for possible solutions
to expected complications during prosthetic
rehabilitation. In addition, with the advent of
greater emphasis on aesthetics in the last
decade, a thorough understanding of the
resorptive pattern and alterations in bony and
mucosal contours post-extraction would
greatly enhance our ability to reconstruct our
patients to a level of optimal function coupled with satisfactory aesthetics.
There have been numerous studies that
have researched the magnitude of hard tissue
changes post-extraction, with the consensus
2 |
Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/121
that alveolar bone loss can be quite marked

after tooth removal (Araujo & Lindhe 2009),
especially in the horizontal dimension (Botticelli et al. 2004). Soft tissue changes
post-extraction have largely been described
qualitatively, and usually as a single entity
together with the hard tissue changes
assessed using serial study casts (e.g. Schropp
et al. 2003).
In recent years, there has been one systematic review addressing the dimensional
changes of the alveolar ridge after tooth
extraction (Van der Weijden et al. 2009);
however, there is as yet no systematic review
addressing the dimensional changes of both
the hard and soft tissues after tooth extraction.
This study aims to review all existing literature published between 1st January 1960
and 30th January 2011, to assess the magnitude of dimensional change of both the hard
and soft tissues of the alveolar ridge after
tooth extraction.
Material and methods

The Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) statement was consulted throughout the process
of this systematic review.
Focused question
What is the magnitude of dimensional

changes in the hard and soft tissues of the
alveolar process, up to 12 months following
tooth extraction?
Search strategy
A comprehensive and systematic electronic

search of both the MEDLINEPubmed database and the Cochrane Central Register of
Controlled Trials (CENTRAL) was conducted, for articles published in English
between 1st January 1960 and 30th June
2010 in the dental literature. The search
was performed again at a later stage, to
include any relevant new studies published
between 1st July 2010 and 31st January 2011. The following key words were
used:
OR
<[text words] Tooth AND Extraction>)
AND
Outcome:
(<[MeSH terms/all subheadings] Bone

Resorption OR Alveolar Bone Loss OR
Periodontal Atrophy>
OR
<[text words] Bone Defect OR Bone Resorption OR Alveolar Bone Loss OR Alveolar
Resorption OR Alveolar Healing OR Ridge
Changes OR Ridge Alterations OR Ridge
Resorption OR Ridge Healing OR Mucosal
Alterations OR Mucosal Changes OR Mucosal Atrophy OR Mucosal Healing OR Gingival Alterations OR Gingival Changes OR
Gingival Atrophy OR Gingival Healing OR
Socket Healing OR Socket>)
The following journals between 2004 and
2010 inclusive, were hand-searched for relevant articles: Clinical Oral Implants
Research, International Journal of Oral &
Maxillofacial Implants, Implant Dentistry,
Journal of Periodontology, Journal of Clinical
Periodontology and Journal of Oral Implantology.
Furthermore, the bibliographies of all publications selected for inclusion in this review
were also scanned for potentially relevant
articles.
Selection criteria
Studies were included if they were published

in English and conducted on human subjects,
with the intervention being tooth extraction,
and the outcome to be assessed in the form
of changes in the clinical or radiographic
alveolar bone dimensions, as well as dimensional soft tissue changes. Similarly, exclusion criteria were applied; letters and
narrative or retrospective reviews, single case
reports, case series with less than three cases,
and third molar extraction cases were all
excluded. Only studies reporting on undisturbed post-extraction dimensional changes
relative to a fixed reference point over a
clearly stated time period were included. In
addition, in the event of duplicate publications, the study with the most inclusive data
was preferentially selected.
Intervention:
(<[MeSH terms/all subheadings] Tooth

Extraction>
OR
<[text words] Tooth Extraction OR Dental
Extraction OR Tooth Removal OR Tooth
Pulling OR Tooth Loss OR Exodontia OR
Surgery OR Surgical Tooth Extraction OR
Surgical Tooth Removal>
Selection of studies
Screening was performed independently by

two reviewers (L. T. Wong and W. L. Tan);
any disagreement between the reviewers was
resolved by discussion. The initial electronic
search resulted in the identification of 2843
titles from the MEDLINEPubmed database
and 1111 titles from the Cochrane Central
Potentially relevant
publications identified from
electronic search of
Cochrane Central Register of
Controlled Trials (CENTRAL)
st
database from 1 January
th
1960 to 30 June 2010
(n = 1111)
Potentially relevant
publications identified from
electronic search of
MEDLINE-Pubmed database
st
th
from 1 January 1960 to 30
June 2010
(n = 2843)
Publications excluded on the basis of title

and summary evaluation; also excluded
duplicate publications
(n = 3716)
Potentially relevant full texts
retrieved for detailed
evaluation
(n = 104)
Publications excluded on the basis of full
text evaluation
(n = 85)
Studies included based on
the initial electronic search of
the MEDLINE-Pubmed and
st
CENTRAL database from 1
th
January 1969 to 30 June
2010
(n = 19)
Register of Controlled Trials (CENTRAL).

After careful independent screening of the
titles and elimination of duplicate titles by
both the examiners, a total of 238 titles were
considered for possible inclusion. Retrieval of
the 238 abstracts and further perusal led to
104 full-text articles being selected. From
these full-text articles, 19 were identified for
inclusion in the review.
Another article was deemed suitable from
the secondary electronic search, but no additional publications from the hand-search or
the bibliography search of the selected articles were identified for inclusion.
In total, 20 articles were identified for
eventual inclusion in this review (Fig. 1).
A j-score of 0.84 was obtained, for consensus between the two reviewers.
Exclusion of studies
Publications included based on the handsearch and bibliography search of

relevant articles
(n = 0)
Publications included based on the

secondary electronic search of the
MEDLINE-Pubmed and CENTRAL
st
st
database from 1 July 2010 to 31
January 2011
(n = 1)
Studies included in the

present systematic review
(n = 20)
Fig. 1. Search strategy. Post-extraction dimensional changes.
Of the 104 full-text articles examined, 85

were excluded from the final analysis
(Table 1). The main reasons for exclusion
were that there were no actual measurements of the dimensional changes of the
alveolar ridge, the reported parameters were
not useful for this review and that there was
the presence of a foreign material in the
extraction site during the healing phase,
among other reasons.
Data collection
From the selected papers that met the criteria, data addressing dimensional changes
Table 1. Studies failing to meet inclusion criteria

Reference
Rationale for exclusion
Richardson 1965; Guglielmotti & Cabrini 1985; Guglielmotti et al. 1985; Mathai et al. 1989;
Ubios et al. 1991; Boyne 1995; Gauthier et al. 1999; Teofilo et al. 2001; Brandao et al. 2002;
Indovina & Block 2002; Magro-Ernica et al. 2003; Altundal & Guvener 2004; Bianchi et al. 2004;
Gorustovich et al. 2004; Nevins et al. 2006; Ortega et al. 2007; Araujo et al. 2008; Iino et al. 2008;
Agbaje et al. 2009; Puia et al. 2009; Alissa et al. 2010; Normando et al. 2010
Pietrokovski & Massler 1967a; Matsumoto 1968
Amemori 1966; Mizutani & Ishihata 1976; Olson & Hagen 1982; Hahn et al. 1988; Oltramari et al.
2007; Shi et al. 2007; Fickl et al. 2008a; Fickl et al. 2008b
Loo 1968; Ashman & Bruins 1985; Ashman & Bruins1987; Scheer & Boyne 1987; Sclar 1999;
Minsk 2005
Guglielmotti et al. 1986; Hsieh et al. 1995; Fickl et al. 2008c; Rothamel et al. 2008; Araujo &
Lindhe 2009a; Pessoa et al. 2009
Reported parameters not relevant or not useful
Carlsson & Persson 1967; Pietrokovski & Massler 1967b; Pietrokovski 1967; Green et al. 1969;
Huebsch & Hansen 1969; Berkovitz 1971; Pietrokovski & Massler 1971; Hars & Massler 1972;
Librus et al. 1973; Thilander & Astrand 1973; Horn et al. 1979; Olson et al. 1982; Quinn &
Kent 1984; Lavelle 1985; Boyes-Varley et al. 1988; Magro-Filho & de Carvalho 1990; Dayan
et al. 1992; Alves-Rezende & Okamoto 1997; Anitua 1999; Pinto et al. 2002; Carmagnola
et al. 2003; Cardaropoli et al. 2005; Smith 1974; Ahn & Shin 2008; Serino et al. 2008; Sharan &
Madjar 2008; Luvizuto et al. 2010; Teofilo et al. 2010
Bergstedt et al. 1973; Michael & Barsoum 1976; Kangvonkit et al. 1986; Sattayasanskul et al.
1988
Bahat et al. 1987; Iizuka et al. 1992; Yugoshi et al. 2002; Araujo et al. 2005; Lindeboom et al.
2006; Wu et al. 2008; Araujo & Lindhe 2009b; Nevins et al. 2009
Araujo & Lindhe 2005
Length of observation period not reported

Studies carried out on animals
Descriptive report on procedure/ technique;
commentary
No baseline data available for comparison, thus unable
to arrive at an estimate of dimensional change over
time
No measurements of alveolar dimensional changes (e.g.
description of healing process or bony shape change,
or histology only)
Study subjects had immediate dentures after extraction,

hence they did not have undisturbed healing
post-extraction
Sample did not include untreated/undisturbed extraction
sockets left to heal spontaneously
Only measured relative difference in height between
buccal and lingual plates of the alveolus
3 |
of both soft and hard tissues of the alveolar

ridge were retrieved for analysis. Mean
values and standard deviations, where
available, were extracted in duplicate by
the two reviewers (L. T. Wong and W. L.
Tan).
Quality assessment
Assessment of study quality was performed

for all the included papers. The Cochrane
Collaborations tool for assessing risk of bias
was used in the case of randomized controlled clinical trials and controlled clinical
trials. Methodological quality assessment of
cohort studies was based on the Newcastle
Ottawa Quality Assessment Scale for Cohort
studies (Tables 2 and 3).
Data synthesis
Preliminary evaluation of the selected publications revealed that there was considerable
heterogeneity between the studies with
regard to study design, study population,
study period, method of assessment of
dimensional change of the alveolar ridge as
well as reference point from which the
changes were measured. Taking this into
consideration, it was not appropriate to conduct a quantitative data synthesis for all
studies, leading to a meta-analysis. In this
case, we attempted to report the data by
applying descriptive methods. In addition,
as a selected few of the included studies
demonstrated some similarity in measurement methods and reference points, we presented weighted means of the dimensional
change of the alveolar ridge over time as
appropriate, taking into account the values
of the relevant standard deviation and
applying inverse variance weighting (Meier
1953).
Inverse variance weighting
For the weighted mean of the list of data for

which each mean xi comes from a different
probability distribution with a known
variance ri2, the weight for each study is
given by:
Wi
1
ri2
The weighted mean in this case is:

Pn
xi =r2i
x Pi1
n
2
i1 1=ri
and the variance of the weighted mean is:
r2x Pn
2
i1 1=ri
4 |
Assessment of heterogeneity
Statistical heterogeneity between all the

included studies was not assessed because all
the studies had different observation time
points as well as measurement methods,
making a statistical comparison impossible.
However,
assessment
of
heterogeneity
between studies with similar characteristics
were performed using Cochrans Q-test:
Q
wi xi x
The P-value was then calculated for the Q

statistic and a value of P < 0.05 would indicate significant statistical heterogeneity
between the studies.
When Q > df, where df is its degree of freedom, the I2 index was also calculated using
the following formula:
I2

Q df
100%
Q
where, I2 = 0% to 40% would indicate

there is little to no heterogeneity
I2 = 30% to 60% would indicate there is
moderate heterogeneity
I2 = 50% to 90% would indicate there is
substantial heterogeneity
I2 = 75% to 100% would indicate considerable heterogeneity
Similarly, the P-value was calculated for
the I2 statistic, and a value of P < 0.05 would
indicate a result that is statistically significant.
Results
Collectively, a total of 20 studies satisfied
the inclusion criteria and were included in
this systematic review.
The 20 studies included 11 randomized
controlled clinical trials, five controlled clinical trials and four cohort studies (Tables 2
and 3). The majority of studies did not state
the reasons for tooth extraction, but in the
studies that did, they included fractures, caries, trauma, endodontic, prosthodontic,
orthodontic and periodontal reasons. Thirteen
papers only studied non-molar extraction
sites (Carlsson & Persson 1967; Lekovic et al.
1997, 1998; Yilmaz et al. 1998; Camargo
et al. 2000; Iasella et al. 2003; Serino et al.
2003; Fiorellini et al. 2005; Saldanha et al.
2006; Rodd et al. 2007; Barone et al. 2008;
Aimetti et al. 2009; Pelegrine et al. 2010),
while six studies (Bragger et al. 1994; Schropp
et al. 2003; Kerr et al. 2008; Crespi et al.
2009; Moya-Villaescusa & Sanchez-Prez
2010; Rasperini et al. 2010) reported on data
including molar extraction sites and one

study (Oghli & Steveling 2010) did not specify where the extractions were performed.
Most of the data extracted concerned teeth in
control groups of studies that evaluated various ridge preservation procedures (Lekovic
et al. 1997, 1998; Yilmaz et al. 1998; Camargo et al. 2000; Iasella et al. 2003; Serino et al.
2003; Fiorellini et al. 2005; Barone et al.
2008; Aimetti et al. 2009; Crespi et al. 2009;
Oghli & Steveling 2010; Pelegrine et al. 2010;
Rasperini et al. 2010), but other studies were
either designed specifically to evaluate postextraction alveolar changes (Carlsson & Persson 1967; Schropp et al. 2003; Rodd et al.
2007; Moya-Villaescusa & Sanchez-Perez
2010) or the effect of smoking (Saldanha
et al. 2006) or ultrasound treatment (Kerr
et al. 2008) on these changes. In addition,
one included study (Bragger et al. 1994) was
actually designed to test the effect of
chlorhexidine mouthrinse on post-extraction
healing. Each paper that was included in
this review contributed a number of extraction sites, ranging from three to over a
hundred sites. The age range of the patients
in these studies was between 10.8 and
53.3 years.
Included studies
There were a total of 20 studies addressing

the hard and soft tissue dimensional changes
of the alveolar ridge in humans, with spontaneous undisturbed healing. The studies were
grouped according to the reported changes in
hard tissue, soft tissue, or a combination of
both hard and soft tissue.
Hard tissue changes
Vertical and horizontal linear hard tissue

changes in humans were reported independently or in combination by 17 studies
(Tables 4 and 7).
Vertical linear hard tissue alteration
All 17 studies that reported on post-extraction hard tissue changes looked into the vertical linear dimensional change of the
alveolus. Eight studies (Lekovic et al. 1997,
1998; Camargo et al. 2000; Iasella et al. 2003;
Serino et al. 2003; Barone et al. 2008; Aimetti
et al. 2009; Pelegrine et al. 2010) utilized
re-entry procedures with stents or titanium
pins as reference points (Fig. 2), one other
study (Rasperini et al. 2010) did not carry out
a re-entry procedure but nevertheless utilized
a stent for reference. An additional eight
studies (Carlsson & Persson 1967; Bragger
et al. 1994; Schropp et al. 2003; Fiorellini
et al. 2005; Saldanha et al. 2006; Kerr et al.
Table 2. Cochrane Collaborations tool for assessing risk of bias

Carlsson & Persson (1967)
Controlled clinical trial
Parallel
Bragger et al. (1994)

Randomized controlled clinical trial
Parallel
Adequate sequence generation

Remark
No
Quote alternate patients were assigned to respective
groups
Unclear
Quote then randomly assigned
Allocation concealment
Remark
Blinding
Remark
Incomplete outcome data addressed
Remark
Unclear
No information provided.
Unclear
Study did not address this outcome.
Yes
Quote one patient from each group had to be
discarded.one had movedother case first radiograph
unsuccessful and could not be repeated..
Yes
Study design
Free of selective reporting

Remark
Free of other sources of bias

Remark
Overall risk of bias
High
High
Study design
Lekovic et al. (1997)

Split-mouth
Lekovic et al. (1998)

Split-mouth

Remark
Unclear
No information provided
Remark
Blinding
Remark
Unclear
Unclear
Study did not address this outcome

Remark
Yes
Mentioned that three patient had dehiscence in test
group, hence did not measure values at 6 months;
re-entry was planned at 6 months, but if membrane
exposure occurred, re-entry and measurements was
done at 3 months. Refer to Tables 35 and will see that
they analysed the results with various combinations,
including with or without the patients that exited early,
suggesting an intention-to-treat analysis
Yes
Yes
Quote control and experimental sites were assigned by
the flip of a coin
Unclear
Yes
Quote clinical measurements were performed by one
clinician who did not have knowledge of control and
experimental sites
Yes
No missing outcome data

Remark
Remark
Yes
Insufficient information about sequence generation

Unclear
Yes
Quote double-blind clinical trial
No
Initially mentioned that 40 patients were enrolled in
study, but subsequently only obtained radiographs for
23 patients with no explanation
No
Initially mentioned that 40 patients were enrolled in
study, but subsequently only obtained radiographs for
23 patients with no explanation
Yes
Yes
Yes
Yes
Unclear
Unclear
Camargo et al. (2000)

Split-mouth
Iasella et al. (2003)

Randomized controlled
clinical trial
Parallel

Parallel and split-mouth
Fiorellini et al. (2005)

Randomized controlled clinical
trial
Parallel
Adequate sequence
generation
Remark
Unclear
Yes
Unclear
Unclear
Quote randomly selected

using a coin toss
Allocation
concealment
Remark
Blinding
Remark
Unclear
Unclear
Unclear
Quote cohorts of 40 patient

randomized in a double-blind
manner
Insufficient information about
sequence generation
Unclear
Unclear
Study did not address this
outcome
Yes
Quote measurements were
taken by 2 masked
examiners
Unclear
Incomplete outcome
data addressed
Yes
Yes
Yes
Study design
Serino et al. (2003)
5 |
Yes
Quote all the patients in the study
underwent the same surgical
procedure, regardless of the
treatment
Yes
Table 2. (continued)
Camargo et al. (2000)
Iasella et al. (2003)

Randomized controlled
clinical trial
Parallel
Serino et al. (2003)
Fiorellini et al. (2005)

trial
Parallel

Parallel and split-mouth
Quote nine subjects
dropped out from the
study for reasons unrelated
to the therapy
Yes
Quote No subjects were

withdrawn or lost to follow-up
Study design

Split-mouth
Remark
Free of selective
reporting
Remark
Free of other sources
of bias
Remark
Yes
Quote implants were

successfully placed at all
sites.none have been
subsequently lost
Yes
Yes
Yes
Yes
Yes
Unclear
Unclear
Unclear
Unclear
Barone et al. (2008)
Kerr et al. (2008)

Parallel

Split-mouth
Yes
Quote using a
computer-generated
randomisation list
Unclear
Quote one site was assigned
randomly as test, whereas the
other site was assigned as control
Remark
Unclear

sequence generation
Unclear
Blinding
Remark
Yes
Quote all measurements were
taken by one examiner who was
not involved in performing the
surgical treatment
Yes
No loss to follow-up in test and
control group
Yes
Study design
Remark

Remark
Remark
Remark
Yes
Quote examiner was masked as to
whether sites were test or control
Yes
Yes
Aimetti et al. (2009)

trial
Parallel
Unclear
Quote were consecutively
selected.. and all sockets were
measured and assigned randomly
to test or control
sequence generation
No
Assignment not explicitly
concealed
Yes
Quote recorded by the same
examiner, who was not involved
in providing therapy
Yes
Unclear
Study did not address this
outcome
Yes
Yes
Yes
Yes
Unclear
Unclear
High
Crespi et al. (2009)
Pelegrine et al. (2010)

Split-mouth

Parallel
Rasperini et al. (2010)

trial
Parallel
No
Quote sockets on right side of jaw
received MHA.sockets on left
side received CS
Unclear
Quote teeth to be extracted were
randomized into two groups
Allocation by left or right side

of jaw
Unclear

sequence generation
Unclear
Blinding
Remark
Yes
Quote a masked examiner
measured the bone level changes.
Unclear

Remark
Yes
Unclear
Study did not address this outcome.

Remark
Remark
Yes
Yes
Yes
Quote treatment regimens
assigned randomly
communicated to the operator
immediately after tooth
extraction
Yes
Quote tubes included into the
stent by a blind examiner..after
surgery, blinded examiner
positioned the stent.
Yes
Missing outcome data balanced in
numbers across groups
Yes
Yes
Yes
Yes
High
Unclear
Low
Study design
Remark
Remark
6 |
Yes
Quote treatment regimens were
assigned randomly to the subjects
with a balanced random permuted
block approach
Table 2. (continued)
Study design
Yilmaz et al. (1998)

Parallel
Oghli & Steveling (2010)

Parallel

Remark
Unclear
Remark
Blinding
Remark
Remark
Remark
Remark
Unclear
Unclear
Unclear
Yes
Unclear
Quote patients were divided randomly into three groups
Insufficient information about sequence generation
Unclear
Unclear
Yes
All exclusions accounted for
Yes
Yes
Yes
Unclear
Unclear
2008; Crespi et al. 2009; Moya-Villaescusa &

Sanchez-Perez 2010) utilized imaging methods to obtain the required information.
Only one re-entry study (Aimetti et al.
2009) addressed the vertical linear change of
the alveolar hard tissue post-extraction at
3 months. In this study, 3 months after
extraction of anterior maxillary teeth, a mean
vertical reduction of 1.2 0.8 mm on the
buccal, 0.9 1.1 mm on the palatal and
0.5 0.9 mm on the mesial and distal sites
were reported when an acrylic stent was used
as a fixed reference during re-entry.
A total of six re-entry studies (Lekovic et al.
1997, 1998; Camargo et al. 2000; Iasella et al.
2003; Serino et al. 2003; Pelegrine et al. 2010)
reported data on 6-month post-extraction vertical linear hard tissue changes of the alveolus;
four studies (Lekovic et al. 1997, 1998; Camargo et al. 2000; Pelegrine et al. 2010) utilized a
titanium screw or pin, while two studies (Iasella et al. 2003 and Serino et al. 2003) used an
acrylic stent as a fixed reference point.
Six months following the extraction of
anterior teeth or premolars, Lekovic et al.
(1997) reported a mean reduction of
1.2 0.13 mm in buccal vertical ridge height,
while Lekovic et al. (1998) and Camargo
et al. (2000) reported a mean reduction of
1.50 0.26 mm and 1.00 2.25 mm respectively. Later, Pelegrine et al. (2010) showed
that 6 months after extraction of maxillary
anterior teeth, the mean buccal vertical alveolar
ridge
height
reduction
was
1.17 0.26 mm. All the four studies mentioned above measure changes relative to a
titanium pin or screw at re-entry.
Iasella et al. (2003) and Serino et al. (2003)
utilized re-entry procedures and acrylic stents
as fixed references, 6 months after extraction
of non-molar teeth. The former study reported
an average alveolar vertical hard tissue reduc 2011 John Wiley & Sons A/S
tion of 0.9 1.6 mm at the mid-buccal,

0.4 1.0 mm at the mid-lingual, 1.0 0.8
mm at the mesial and 0.8 0.8 mm on the
distal sites; the latter study recorded a mean
reduction of 0.7 1.2 mm on the buccal.
Taking into consideration the similarities
between these six re-entry studies that
reported 6-month data (Lekovic et al. 1997,
Serino et al. 2003; Pelegrine et al. 2010), the
weighted mean was calculated for the relevant sites, using the inverse variance
method, to give a more robust value of the
6-month post-extraction vertical change
(Fig. 3). On the buccal, all six studies were
included to give a weighted mean reduction
of 1.24 0.11 mm (Q = 1.3, P = 0.94). Only
two studies (Iasella et al. 2003; Serino et al.
2003) were included when mesial and distal
sites were investigated; the respective
weighted reductions were 0.84 0.62 mm on
the
mesial
(Q = 0.10,
P = 0.75)
and
0.80 0.71 mm on the distal (Q = 0, P = 1).
After a 7-month undisturbed healing period
in non-molar extraction sites, Barone et al.
(2008) observed vertical linear reduction of
3.6 1.5 mm, 3.0 1.6 mm, 0.4 1.2 mm
and 0.5 1.0 mm on the mid-buccal, mid-lingual, mesial and distal sites respectively, at reentry. A stent was used as a fixed reference.
Rasperini et al. (2010) reported on 3- and 6month dimensional changes of the alveolar
ridge after extraction of maxillary molar
teeth, using a custom acrylic stent and a periodontal probe or endodontic file to obtain the
measurements; measurements were made
from the surface of the bone to the external
surface of the stent. The observed reduction
in height of the buccal plate at 3 and
6 months were 2.2 and 5.7 mm respectively,
when the buccal plates were intact after
extraction. However, when the buccal plates
were lost at time of extraction, there was a

corresponding gain of buccal bone height of 1
and 0.6 mm at 3 and 6 months respectively.
Radiographic methods used for the relevant
studies were: lateral cephalometric radiography in one study (Carlsson & Persson 1967),
cone beam computed tomography in two
studies (Fiorellini et al. 2005 and Kerr et al.
2008), linear tomography in one study (Saldanha et al. 2006), and intraoral peri-apical radiography in four studies (Bragger et al. 1994;
Schropp et al. 2003; Crespi et al. 2009 and
Moya-Villaescusa & Sanchez-Perez 2010).
Carlsson & Persson (1967) attempted to
use lateral cephalometric radiography to demonstrate the longitudinal height change in
the mandibular alveolar ridge after extraction
of at least five to six lower anterior teeth and
loading with conventional full dentures
2 months post-extraction. The study had
observation time points at 2, 4, 6, 12, 24 and
60 months. The reductions in alveolar height
were 2.0 mm at 2 months, 2.9 mm at
4 months, 3.4 mm at 6 months and 4.1 mm
at 12 month, compared to baseline. From this
study, we can see a trend where there is a
large reduction in alveolar bone height in the
first 2 months post-extraction, followed by a
continual gradual resorption thereafter. Take
note that we should interpret the values
obtained in this study, with observation time
points greater than 2 months, with caution;
2 months after teeth extraction, full dentures
were inserted in the conventional group, and
we cannot with full confidence, state that
insertion and use of denture prostheses did
not have an impact on the resorptive pattern
and extent of the alveolar hard and soft tissues in this case.
Two studies (Fiorellini et al. 2005; Kerr
et al. 2008) utilized computed tomography to
detect vertical height changes in the alveolar
7 |
Table 3. NewcastleOttawa Quality Assessment Scale for Cohort Studies (max 9*)
Study design
Selection
Representativeness of the exposed
cohort
Rating
Selection of non exposed cohort
Rating
Ascertainment of exposure
Rating
Demonstration that outcome of
interest was not present at
start of study
Rating
Comparability
Comparability of cohorts on the
basis of the design or analysis
Rating
Outcome
Assessment of outcome
Rating
Was follow-up long enough for
outcomes to occur
Rating
Adequacy of follow up of cohorts
Rating
Overall
Schropp et al. (2003)

Cohort
Saldanha et al. (2006)

Cohort
Truly representative of the average implant

patient in the community
*
No description of the derivation of non-exposed
cohort
Representative of the average patient

requiring extraction in the community
*
No description of the derivation of the non-exposed
cohort
Secure record (radiograph, study model, clinical

exam)
*
Yes
Secure record (radiograph, linear tomography, clinical

exam)
*
Yes
No mention of control of any confounding factors (e.g.

smoking, health)
Controlled for confounding factors (smoking, oral

hygiene, ethnicity, systemic health)
**
Records (radiograph, study models)

*
Yes; 12 months follow up (early soft/hard tissue healing
usually 68 weeks)
*
Description of those lost to follow-up
*
6*
Independent blind assessment

*
Yes; 6 months (early hard tissue healing usually
68 weeks)
*
No statement
Study design
Selection
Representativeness of the exposed
cohort
Rating
Selection of non exposed cohort
Rating
Ascertainment of exposure
Rating
Demonstration that outcome of interest
was not present at start of study
Rating
Comparability
Comparability of cohorts on the basis
of the design or analysis
Rating
Outcome
Assessment of outcome
Rating
Was follow-up long enough for
outcomes to occur
Rating
Adequacy of follow up of cohorts
Rating
Overall
Rodd et al. (2007)

Cohort
Moya-Villaescusa & Sanchez-Perez (2010)

Cohort
Truly representative of the average young patient

with dental trauma in the community
*
cohort
Representative of the average patient requiring

extraction in the community
*
cohort
Secure record (study model, photograph, clinical

exam)
*
Yes
Secure record (radiograph, clinical exam)
Sample size too small to allow statistical

adjustment of confounders
Controlled for confounding factors (smoking, number

of roots, oral hygiene, periodontal disease)
**
Records (study model, photograph)

*
Yes; 461 months follow up (early soft/hard tissue
healing usually 68 weeks)
*
No statement
Records (radiograph)
*
Yes; 3 months follow up (early hard tissue healing
usually 68 weeks)
*
No statement
5*
7*
hard tissue. Fiorellini et al. (2005) reported a

4-month
mean
height
reduction
of
1.17 1.23 mm in patients after extraction
of maxillary non-molar teeth; of note is that
all the patients in this sample had a buccal
defect of 50% bone loss of the extraction
socket at baseline. In the study by Kerr et al.
(2008), following extraction of a permanent
tooth, the corresponding vertical resorption
8 |
7*
*
Yes
of the alveolar ridge were 1.01 0.39 mm on

the buccal, 0.62 0.28 mm on the lingual at
1 month and 0.95 0.39 on the buccal,
1.12 0.28 on the lingual at 3 months.
Six months after extraction of upper anterior teeth, Saldanha et al. (2006) observed a
vertical resorption of 1.5 mm in smokers and
1.0 mm in non-smokers when using linear
tomography.
Assessing interproximal bone height

change on intraoral periapical radiographs,
Bragger et al. (1994) demonstrated a vertical
reduction
of
0.61 0.67 mm,
0.67
0.66 mm, 1.19 1.50 mm and 0.93 0.74
mm at 1, 2, 3 and 6 months respectively,
while Schropp et al. (2003) documented a
0.3 mm loss at 12 months. Crespi et al.
(2009) went on to show an overall 3-month
Table 4. Characteristics of studies included for hard tissue change only
Title
Morphologic changes of the mandible after extraction
and wearing of denture
Effect of chlorhexidine(0.12%) rinses on periodontal
tissue healing after tooth extraction(II)radiographic
parameters
A bone regeneration approach to alveolar ridge
maintenance following tooth extraction. Report of
10 cases
Preservation of alveolar bone in extraction sockets
using bioabsorbable membranes
Influence of bioactive glass on changes in alveolar
process dimensions after exodontia
Ridge preservation with freeze-dried bone allograft
and a collagen membrane compared to extraction
alone for implant site development: a clinical and
histological study in humans
Ridge preservation following tooth extraction using
a polylactide and polyglycolide sponge as space filler:
a clinical and histological study in humans
Bone healing and soft tissue contour changes
following single-tooth extraction: a clinical and
radiographic 12-month prospective study
Randomized study evaluating recombinant human
bone morphogenetic protein-2 for extraction socket
augmentation
Smoking may affect the alveolar process dimensions
and radiographic bone density in maxillary extraction
sites: a prospective study in humans
Xenograft vs. extraction alone for ridge preservation
after tooth removal: a clinical and histomorphometric
study
The effect of ultrasound on bone dimension changes
following extraction: a pilot study
Clinical and histological healing of human extraction
sockets filled with calcium sulphate
Magnesium-enriched hydroxyapatite compared to
calcium sulphate in the healing of human extraction
sockets: radiographic and histomorphometric
evaluation at 3 months
Measurement of ridge alterations following tooth
removal:a radiographic study in humans
Clinical and histomorphometric evaluation of
extraction sockets treated with an autologous bone
marrow graft
Socket grafting in the posterior maxilla reduces the
need for sinus augmentation
loss of 3.75 0.63 mm when the buccal plate

was lost during extraction. One study (MoyaVillaescusa & Sanchez-Prez 2010) further
discerned between the bone loss at 3 months
after extraction of single-rooted teeth
(4.16 0.32 mm) vs. multiple-rooted teeth
(4.48 0.39 mm loss), although the difference was not statistically significant. The
average bone loss when both groups were
combined was 4.32 0.24 mm.
Percentage change of vertical linear hard tissue
alteration
All the four re-entry studies (Lekovic et al.

1997, 1998; Camargo et al. 2000; Pelegrine
et al. 2010) utilizing a titanium pin or screw
had data on the baseline internal socket
height. This facilitated a calculation of the
Methods
Sample
size
No. of
extraction
sites
Radio
17
56 per pt
Hard
Radio
12
21
CCT
Hard
Re-entry (pin)
10
10
Human
RCCT
Hard
16
16
Camargo 2000
Human
CCT
Hard
16
16
Iasella 2003
Human
RCCT
Soft
+ hard
Re-entry
(pin 25 mm)
Re-entry
(pin 18 mm)
Re-entry
(stent)
12
12
Serino 2003
Human
CCT
Hard
Re-entry
(stent)
12
13
Schropp 2003
Human
Cohort
Hard
Radio
46
46
Fiorellini 2005
Human
RCCT
Hard
CT scan
20
Saldanha 2006
Human
Cohort
Hard
Radio
21
21
Barone 2008
Human
RCCT
Hard
Re-entry
(stent)
20
20
Kerr 2008
Human
RCCT
Hard
12
12
Aimettl 2009
Human
RCCT
Hard
18
18
Crespi 2009
Human
RCCT
Hard
CBVT (ref
plate)
Re-entry
(stent)
Radio
15
15
Moya-Villaescusa
2010
Pelegrine 2010
Human
Cohort
Hard
Radio
100
100
Human
RCCT
Hard
Re-entry (pin)
15
Rasperini 2010
Human
RCCT
Hard
Stent
Author,
publishing year
Species
QA
Tissue
Carlsson 1967
human
CCT
Hard
Bragger 1994
Human
RCCT
Lekovic 1997
Human
Lekovic 1998
percentage reduction of the vertical dimension of the alveolus post-extraction as follows:

%vertical linear change hard tissue
vertical linear resortion hard tissue
baseline internal socket height

The calculated percentage vertical change
of the alveolar hard tissue ranged from 11%
to 22% (Fig. 4) at buccal sites, 6 months
post-extraction.
Horizontal linear hard tissue alteration
A total of eight studies (Lekovic et al. 1997,

Barone et al. 2008; Kerr et al. 2008; Aimetti
et al. 2009; Pelegrine et al. 2010) reported on
horizontal changes over time in the hard tissue at the level of the alveolar crest (Fig. 5).
Two studies (Kerr et al. 2008; Aimetti et al.
2009) reported 3-month horizontal reduction
to be between 2.20 and 3.20 mm; another
study (Barone et al. 2008) reported 7-month
reduction to be 4.5 0.8 mm. Lekovic et al.
(1997, 1998), Camargo et al. (2000), Iasella
et al. (2003) and Pelegrine et al. (2010) documented 6-month horizontal reduction in the
hard tissue of the alveolar ridge to be 4.40,
4.56, 3.06, 2.63 and 2.46 mm respectively.
The five latter studies (Lekovic et al. 1997,
1998; Camargo et al. 2000; Iasella et al. 2003
and Pelegrine et al. 2010) have quite a few
methodological similarities, however, results
of the heterogeneity testing reveal that there
is considerable heterogeneity between the
9 |
Fig. 5. Horizontal (linear) hard tissue change for reentry studies only.
Fig. 2. Vertical (linear) hard tissue change for re-entry

studies only.
studies (Q = 17.8, P < 0.05; I2 = 77.6%,

P < 0.05). In this case, although the weighted
mean was calculated by applying the inverse
variance method to arrive at a value of
3.79 0.23 mm horizontal reduction at
6 months (Fig. 6) across all five studies, the
robustness and applicability of this value
should be questioned.
Saldanha et al. (2006) reported the horizontal reduction of the alveolar bone at 0% and
50% the distance from the crest. This study
demonstrated a 6-month reduction of 0.6 and
1.3 mm for non-smokers and smokers respectively at 0% from the alveolar crest and corresponding values of 0.1 and 0.8 mm at 50%
from the crest. This study utilized linear
tomography to track the changes.
Of note, Kerr et al. (2008) demonstrated
beautifully that 3 months after tooth extraction, there was a relative decrease in horizontal ridge reduction as the distance from the
alveolar crest increased (Fig. 7).
Percentage change of horizontal linear hard tissue
alteration
All but one study (Kerr et al. 2008) reporting

changes in the ridge width also reported the
10 |
Fig. 3. Vertical (linear) hard tissue change for re-entry

studies only; weighted means shown.
Fig. 6. Horizontal (linear) hard tissue change for reentry studies only; weighted means shown.
The calculated percentage horizontal

change of the alveolar hard tissue at the alveolar crest ranged from 32% at 3 months, and
between 29% and 63% after 67 months
post-extraction (Fig. 8).
Overall hard tissue changes
Fig. 4. Vertical (linear) hard tissue percentage change in

four studies.
baseline ridge width immediately post-extraction. This facilitated a calculation of the percentage reduction of the horizontal dimension
of the alveolus post-extraction as follows:
%horizontallinear changehard tissue
horizontal linear resortionhard tissue
baseline internal socket height
In general, with regard to vertical dimensional change, we can see a trend where
there is a greater reduction on the buccal and
lingual sites as compared to the mesial and
distal sites. Looking at the horizontal dimensional change, there is a distinct pattern of
resorption where the resorption decreases
with increased distance from the alveolar
crest. Overall, the observed horizontal resorption of the hard tissues (2963%) is far
greater than the resorption in the vertical
dimension (1122%), over an observation period of 37 months. It can be seen that the
bulk of the resorption occurs in the first
3 months post-extraction, and the changes
are much more subtle thereafter.
Fig. 9. Change in soft tissue dimensions over time.
Fig. 8. Horizontal
change.
(linear)
hard
tissue
percentage
sue thickness at 6 months, measured at buccal and lingual sites 3 mm from the alveolar
crest. Occlusally, soft tissue with thickness
of 2.1 mm developed after 6 months to complete soft tissue coverage of the wound
(Fig. 9).
Combined hard and soft tissue changes
Fig. 7. Horizontal (linear) hard tissue change with

respect to distance from alveolar crest.
Soft tissue changes
Only a single study (Iasella et al. 2003)

reported on longitudinal changes of soft tissue dimensions in the alveolus post-extraction
(Tables 5
and
7).
This
study
demonstrated a 0.40.5 mm gain of soft tis-
To date, a total of five studies (Carlsson &

Persson 1967; Yilmaz et al. 1998; Schropp
et al. 2003; Rodd et al. 2007; Oghli & Steveling 2010) presented data on the longitudinal
change in the combined hard and soft tissue
dimension of the alveolus post-extraction
(Tables 6 and 7). One study (Carlsson & Persson 1967) utilized lateral cephalometric radiography whereas study casts were employed
in the other four studies (Yilmaz et al. 1998;
Schropp et al. 2003; Rodd et al. 2007; Oghli
& Steveling 2010). Vertical and horizontal
linear tissue alterations were reported inde-
pendently or in combination; in one study

(Rodd et al. 2007) the overall areal change of
the alveolar hard and soft tissue combined,
was reported.
Vertical linear combined hard and soft tissue
alteration
Three studies (Carlsson & Persson 1967; Yilmaz et al. 1998 and Schropp et al. 2003)
addressed the combined hard and soft tissue
changes in the vertical dimension of the alveolus.
With the aid of lateral cephalometric radiography, Carlsson & Persson (1967) was able
to demonstrate the combined hard and soft
tissue changes of the mandibular alveolus in
the vertical dimension over time. The vertical reductions of the conjugated tissue
dimension from baseline were 2.1 mm at
2 months, 2.9 mm at 4 months, 3.4 mm at
6 months and 4.0 mm at 12 month. This
degree of resorption of the combined hard
and soft tissues followed a similar trend as
that of hard tissue alone.
Utilizing sectioned study casts, Yilmaz
et al. (1998) demonstrated a vertical reduction of 0.1 0.52 mm and 0.5 0.76 mm at
Table 5. Characteristic of study included for soft tissue change only

Title
Ridge preservation with freeze-dried bone allograft
and a collagen membrane compared to extraction
alone for implant site development: a clinical and
histological study in humans
Author,
Publishing Year
Species
QA
Tissue
Methods
Sample size
No. of
extraction site
Iasella 2003
Human
RCCT
Soft + hard
Re-entry (stent)
12
12
Table 6. Characteristics of studies included for both hard and soft tissue changes combined
Title
Authors
Species
QA
Tissue
Method
Sample size
No. of
extraction sites
Morphologic changes of the mandible after extraction

and wearing of denture
Alveolar ridge reconstruction and/or preservation
using root form bioglass cones
Bone healing and soft tissue contour changes
following single-tooth extraction: A clinical and
radiographic 12-month prospective study
Change in supporting tissue following loss of a
permanent maxillary incisor in children
Ridge preservation following tooth extraction:
A comparison between atraumatic extraction and
socket seal surgery
Carlsson 1967
Human
CCT
Soft + hard
Radio
17
5/6 per pt
Yilmaz 1998
Human
CCT
Soft + hard
Cast
10
Schropp 2003
Human
CCT
Soft + hard
Cast
46
46
Rodd 2007
Human
Cohort
Soft + hard
Cast
16
16
Oghli 2010
Human
RCCT
Soft + hard
Cast
72
101
11 |
Table 7. Overall results from all studies
Methods
Sample
size
No. of
extraction
sites
Hard
Radio
17
56 per pt
Human
Hard
Radio
12
21
Lekovic 1997
Lekovic 1998
Human
Human
Hard
Hard
(pin)
(pin2
10
16
Camargo 2000
Human
Hard
(pin1
Iasella 2003
Human
Soft+
hard
Re-entry
Re-entry
5 mm)
Re-entry
8 mm)
Re-entry
Iasella 2003
Human
Serino 2003
Vertical dimensional
change
Horizontal dimensional
change
2 month: 2.2(1.1)
12 month: 3.6(0.5)
60 month: 4.0(1.5)
10
16
2 month: 2.0(0.9)
4 month: 2.9(1.7)
6 month: 3.4(2.1)
12 month: 4.1(2.7)
24 month: 4.9(3.7)
60 month: 7.3(3.7)
1 month: 0.61(0.67)
2 month: 0.67(0.66)
3 month: 1.19(1.50)
6 month: 0.93(0.74)
6 month: 1.2(0.13)
6 month: 1.50(0.26)
16
16
6 month: 1.00(2.25)
6 month: 3.06(2.41)
(stent)
12
12
Soft
Re-entry (stent)
12
12
Human
Hard
Re-entry (stent)
12
13
Schropp 2003
Human
Hard
Radio
46
46
Schropp 2003
Human
Soft+
hard
Cast
46
46
Fiorellini 2005
Saldanha 2006
Barone 2008
Human
Human
Human
Hard
Hard
Hard
CT scan
Radio
Re-entry (stent)
20
21
20
?
21
20
Kerr 2008
Human
Hard
CBVT
(ref plate)
12
12
Aimettl 2009
Human
Hard
Re-entry (stent)
18
18
Crespi 2009
Moya-Villaescusa
2010
Pelegrine 2010
Rasperini 2010
Human
Human
Hard
Hard
Radio
Radio
15
100
15
100
6 month: B 0.9(1.6)
6 month: 2.6(2.3)
L 0.4(1.0)
M 1.0(0.8)
D 0.8(0.8)
6 month: B 0.4(0.6)
L 0.5(1.5)
(Soft tissue thickness change)
6 month: B 0.8(1.6)
M 0.6(1.0)
D 0.8(1.5)
12 month: M 0.3
D 0.3
3 month: B 0.1
3 month: 3.8
L 0.8
6 month: 5.1
6 month: B 0.1
12 month: 6.1
L 0.9
12 month: B 0.4
L 0.8
4 month: 1.17(1.23)
6 month: 1.0 to 1.5
6 month: 0.1 to 1.3
7 month: B 3.6(1.5)
7 month: 4.5(0.8)
L 3.0(1.6)
M 0.4(1.2)
D 0.5(1.0)
1 month:B 1.01(0.39)
1 month: 0.16(0.96)
L 0.62(0.28)
0.62(0.24)
3 month:B 0.95(0.9)
0.26(0.17)
L 1.12(0.28)
0.10(0.10)
3 month: 2.20(0.81)
1.30(0.24)
0.59(0.17)
0.28(0.10)
3 month: B1.2(0.6)
L 0.9(1.1)
M 0.5(0.9)
D 0.5(1.1)
3 month: 3.75(0.63)
3 month: 4.32(0.23)
Human
Human
Hard
Hard
Re-entry (pin)
Stent
6
3
15
3
Yilmaz 1998
Human
Hard
Cast
10
Rodd 2007
Human
Hard
Cast
16
16
Oghli 2010
Human
Hard
Cast
72
101
Author,
Publishing Year
Species
Tissue
Carlsson 1967
Human
Bragger 1994
3 and 12 months respectively, post-extraction of maxillary incisor teeth (Fig. 10).

Schropp et al. (2003) took measurements
from study casts taken immediately after as
12 |
6 month: 1.17(0.26)
3 month: 2.2
6 month: 5.7(4.2)
3 month: 0.1(0.52)
12 month: 0.5(0.76)
3 month: 15.7%
6 month: 25.3%
9 month: 22%
(Bone surface area)
well as 3, 6 and 12 months after extraction

of maxillary posterior teeth. Taking the
occlusal surfaces of adjacent teeth as reference, a reduction of 0.1 mm at 3 months
6 month: 4.4(0.61)
6 month: 4.56(0.33)
3 month: 0.1(0.23)
12 month: 0.4(0.48)
3 month: 0.3(0.5)
was followed by a net gain of 0.1 mm at

6 months and 0.4 mm at 12 months of the
buccal sites. Lingual sites demonstrated a
loss of 0.80.9 mm between 3 and 6 months,
always more substantial than the vertical

change.
Discussion
Fig. 11. Horizontal (linear) change of hard and soft tissues combined.
Fig. 10. Vertical (linear) change of hard and soft tissues

combined.
with a net loss of 0.8 mm at 12 months

(Fig. 10).
Horizontal linear combined hard and soft tissue
alteration
Four studies (Carlsson & Persson 1967; Yilmaz et al. 1998; Schropp et al. 2003; Oghli &
Steveling 2010) presented data on the combined hard and soft tissue change in the horizontal dimension following extraction.
The only study using radiographic methods
(Carlsson & Persson 1967) demonstrated a
reduction of the alveolar width in the magnitude of 2.2 mm at 2 months, which subsequently increased to 3.6 mm at 12 months;
this measurement was taken 3 mm from the
alveolar crest.
Study casts were used in some of the studies (Yilmaz et al. 1998; Schropp et al. 2003;
Oghli & Steveling 2010) to evaluate the
change in the horizontal dimension (Fig. 11).
Yilmaz et al. (1998) showed a 3- and 12month reduction in width of 0.1 0.23 mm
and 0.4 0.48 mm respectively, while Oghli
& Steveling (2010) reported a 3-month reduction of 0.3 0.5 mm. Horizontal resorption
of the alveolar hard and soft tissue between 3
and 12 months was also reported by Schropp
et al. (2003); at 3 months the resorption was
3.8 mm, this increased to 5.1 mm at
6 months and culminated to a value of
6.1 mm at 12 months.
The latter three studies (Yilmaz et al.
1998; Schropp et al. 2003; Oghli & Steveling
2010) had quite many similarities and an
attempt to calculate the weighted means for
these three studies was launched. However,
the study by Schropp et al. (2003) failed to
provide any information on the standard

deviations in the study, so it was impossible
to utilize the inverse variance method to calculate the weighted means.
Cross-sectional surface area alteration of combined
alveolar hard and soft tissues
A single study reported on change in alveolar

surface area of the hard and soft tissues combined (Rodd et al. 2007); measurements were
obtained from study casts acquired prior to,
and at 3, 6 and 9 months following extraction of maxillary central incisors in children.
The reductions in surface area were presented
as a percentage of the surface area on the preextraction cast, and were as follows: 15.7%
at 3 months, 25.3% at 6 months and 22% at
9 months.
Overall combined hard and soft tissue changes
With the aid of various assessment methods,

a longitudinal change of the combined hard
and soft tissues in the vertical dimension
was found to be anywhere between a loss of
4.0 mm to a gain of 0.4 mm over a period of
212 months.
Study casts and radiographs were employed
to assess the reduction of the combined hard
and soft tissues in the horizontal dimension.
This reduction was demonstrated to be
between 0.1 and 6.1 mm when the observation periods varied from 3 to 12 months, and
the measurements were taken at the alveolar
crest. When the measurements were taken
3 mm apical to the alveolar crest, the corresponding horizontal reductions of the combined hard and soft tissues were 2.2 mm at
2 months and 3.6 mm at 12 months. Reductions in cross-sectional surface area of the tissues were up to 22% after 9 months.
Mimicking the changes of the alveolar hard
tissue, there is a similar pattern of resorption
when we look at the combined hard and
soft tissue entity; the horizontal alteration is
The 20 included studies in this systematic

review were of different study designs and
measured dimensional change in various
ways.
Eleven randomized controlled clinical trials, five controlled clinical trials and four
cohort studies were included in this review.
It is common knowledge that randomized
controlled clinical trials and the systematic
review of randomized controlled clinical trials provide the highest level of evidence
related to intervention and therapy. However,
in the case of post-extractional dimensional
changes of the alveolar hard and soft tissues,
there are no randomized controlled clinical
trials where the control procedure is where
the tooth was left in situ and the test procedure was extraction. Hence, the cohort studies where post-extraction alveolar hard and
soft tissues changes were monitored longitudinally might provide better insight and be
the more appropriate study design.
The three main measuring methods utilized were: (i) re-entry (ii) imaging and (iii)
study models. The re-entry method constituted of elevating a flap during extraction
and again at re-evaluation. All the studies
using the re-entry method measured the
parameters from a fixed reference, namely an
acrylic stent or a titanium pin or screw. The
imaging method included the utilization of
periapical radiographs, lateral cephalometric
radiography, or computer tomography. The
method where study models were utilized
required that study impressions be taken
before, or immediately after extraction, and
again at re-evaluation.
Re-entry studies evaluated hard tissue as
well as soft tissues as separate entities, while
imaging studies evaluated either hard tissue
dimension only, or the combined hard and
soft tissue changes. Study model studies
focused on combined hard and soft tissue
dimensional changes. During data analysis
process, we subdivided the data into different
groups, mainly according to measurement
methods and the tissues involved. The
groups include (i) hard tissue group, (ii) soft
tissue group, and (iii) combined hard and soft
tissue group.
Heterogeneity assessment
The 20 included studies had different observation time points, methodologies, and
13 |
measurement methods. Heterogeneity assessment was performed in six re-entry studies

(Lekovic et al. 1997, 1998; Camargo et al.
2000; Iasella et al. 2003; Serino et al. 2003
and Pelegrine et al. 2010) calculating mean
vertical hard tissue change, and five studies
(Lekovic et al. 1997, 1998; Camargo et al.
2000; Iasella et al. 2003 and Pelegrine et al.
2010,) calculating horizontal hard tissue
change. These studies had similarity in terms
of the method of measurements employed.
The studies all employed re-entry methods,
utilizing an acrylic stent or a titanium pin or
screw as a fixed reference from which to
measure the dimensional changes. The differences in sample sizes, different behaviours of
study populations, varied observation time
points and measurement parameters contributed to the heterogeneity. Although weighted
means were calculated, the resultant values
should really only be used for reference purposes. The robustness and applicability of the
weighted means should be interpreted with
caution.
Hard tissue vertical dimensional change
Buccal/lingual vs. mesial/distal
Three studies (Iasella et al. 2003; Barone

et al. 2008; Aimetti et al. 2009) measured
vertical dimensional changes of all the buccal, lingual, mesial and distal bone plates.
Two of the three studies, namely Barone
et al. (2008) and Aimetti et al. (2009), demonstrated that buccal/lingual sites (0.93.6 mm
loss at 37 months) had more resorption than
mesial/distal sites (0.40.5 mm loss at 3
7 months). Referring to the calculated values
of the respective weighted mean, buccal bone
plates (1.24 mm loss at 37 months) also had
a tendency to resorb more than mesial/distal
bone sites (0.80.84 mm at 37 months)
(Fig. 2). One possible explanation for this
trend is that the mesial and distal bone levels
are partially determined by the presence or
absence of neighbouring teeth; mesial/distal
bone levels are held stable by the presence of
adjacent teeth.
Buccal vs. lingual
Iasella et al. (2003), Barone et al. (2008) and

Aimetti et al. (2009) measured vertical
dimensional changes at both buccal and lingual bone plates. All three studies showed
that the buccal plate resorption (0.93.6 mm
at 37 months) was of greater magnitude
than that of the lingual plate (0.43 mm at 3
7 months). This finding was similar to previous studies in the canine model (Araujo &
Lindhe 2005; Araujo et al. 2005). This pattern
14 |
of resorption can be explained by the bundle

bone concept as proposed by Araujo & Lindhe (2005). According to this theory, a larger
proportion of the buccal plate is made up of
bundle bone relative to the lingual plate; as
bundle bone is a tooth-dependent tissue, it is
quickly resorbed after tooth extraction and
with its resorption, a substantial portion of
the buccal plate is lost. In our review of the
literature, however, the relative height difference between the buccal and lingual bone
plates in humans was less marked compared
to the canine model by Araujo & Lindhe
(2005). The relative difference in height of
the buccal and lingual plate is estimated to
be around 0.30.6 mm over a period of 3 and
7 months, in our review. One possible explanation for the observed differences between
human models and canine models is that the
buccal plate in humans is on average equally
prone to resorption as the lingual aspect of
the ridge (Van der Weijden et al. 2009).
Hard tissue horizontal dimensional change
Five re-entry studies (Lekovic et al. 1997,

Pelegrine et al. 2010) showed that there was
range of 2.464.56 mm horizontal bone loss
and weighted mean resorption of 3.79 mm at
6 months. However, theses studies only provided data for horizontal resorption at the
level of the alveolar crest, no data was available on magnitude of horizontal resorption a
distance away from the alveolar crest. Kerr
et al. (2008) demonstrated a relative decrease
in horizontal ridge reduction as the distance
from the alveolar crest increased. This finding was similar to a dog study done by Araujo & Lindhe (2009), which observed more
resorption at coronal third and least resorption at apical third of the alveolar ridge.
Hence, it is expected that the amount of horizontal resorption might be less than
weighted mean of 3.79 mm at 6 months
when the measurement is taken at a distance
from the alveolar crest.
Mesial vs. distal
Four studies (Iasella et al. 2003; Serino et al.

2003; Barone et al. 2008 and Aimetti et al.
2009) measured vertical dimensional changes
of both mesial and distal bone plates. All four
studies showed the extent of resorption to be
between 0.4 and 0.8 mm over an observation
period of 37 months.
Hard tissue vertical dimensional percentage
change
Lekovic et al. (1997, 1998), Camargo et al.

(2000), Pelegrine et al. (2010) reported baseline data of the internal socket height immediately post-extraction. Internal socket height
is a measurement from buccal bone crest to
the bottom of the extraction socket. The provision of baseline internal socket height
enabled us to calculate the percentage change
in height of the buccal bone wall relative to
the baseline height of the buccal bone wall
over time. The percentage change reflected
the amount of vertical resorption of the buccal plate only; this was found to be between
11% and 22% six months post-extraction.
Percentage changes of lingual, mesial and
distal bony plates could not be calculated due
to lack of baseline data, but it is expected to
be less than 1122%, as the amount of
resorption in these areas have been shown to
be of a comparatively lesser magnitude. Correspondingly, from this this percentage, we
can interpret that there might be 7889%
bone fill of the original socket height, calculated as percentage vertical bone fill equals
one minus vertical dimensional percentage
change.
Hard tissue horizontal dimensional percentage

change
There was 32% reduction at 3 months, and

2963% reduction in horizontal dimension
at 6 months. This demonstrated that possibly more than half of the ridge width could
be resorbed after 6 months in some patients.
However, a definite conclusion cannot be
drawn from these data, on whether the
resorption was from the buccal or lingual.
Studies by Pietrokovski & Massler (1967),
Schropp et al. (2003), Araujo & Lindhe
(2005) and Barone et al. (2008) all suggest
that tissue loss is more pronounced on the
buccal aspect than from the lingual or palatal aspect.
Vertical hard tissue vs. horizontal hard tissue
change
The amount of horizontal dimensional

change was found to be greater than that of
the vertical dimension, in both absolute values and percentage change. Horizontal reduction (3.79 0.23 mm) was more than vertical
reduction (1.24 0.11 mm on buccal, 0.84
0.62 mm on mesial and 0.80 0.71 mm on
distal) at 6 months. Percentage vertical
change was 1122% at 6 months while percentage horizontal change was 32% at
3 months, and 2963% between 6 and
7 months.
Soft tissue changes
Only one study by Iasella et al. (2003) was

found to have measured soft tissue thickness
change after extraction. There was a 0.4
0.5 mm gain in soft tissue thickness on buccal and lingual sites at 6 months. Interestingly, from this study, a difference was found
in the change of soft tissue thickness over a
natural healing socket, and sockets augmented using bio-resorbable membranes and
grafts. There was net gain of soft tissue
thickness in the natural healing group and a
net loss in the augmented group. One possible explanation for this observation was that
the membrane or graft placed might have
interfered with the soft tissue vascularity in
the augmented group. We must remember
that the vascular supply to the soft tissue is
derived from the underlying bone, and the
placement of membranes or grafts might
interfere with re-vascularization of the soft
tissues. In contrast, there is no interposing
material between the bone and the overlying
soft tissues in the naturally healing sockets.
Although there was an observed gain in soft
tissue thickness over a naturally healing
socket, a robust conclusion cannot be drawn
from this single study.
In addition, this study also demonstrated a
trend where the lingual soft tissues were
thicker than that on the buccal; lingual soft
tissues were nearly twice as thick. The methods and materials in the study could explain
this difference; majority of teeth extracted
within the study were maxillary teeth where
palatal soft tissue is expected to be much
thicker than that of the buccal. Hence, this
finding may only be applicable to the maxillary extraction sockets, but not mandibular
ones. Note that this study only had a sample
size of 12 non-molar extraction sockets,
hence we should be cautious when trying to
interpret the results of this study.
Vertical combined hard and soft tissue change
Two studies by Yilmaz et al. (1998) and Schropp et al. (2003) demonstrated very subtle
changes in the vertical dimension of the hard
and soft tissues combined, between 3 and
12 months post-extraction. The changes ranged from a gain of 0.1 mm to a loss of
0.9 mm at 6 months and a gain of 0.4 mm to
a loss of 0.8 mm at 12 months. Schropp et al.
(2003) also observed a small increase buccally
and a reduction orally.
Horizontal combined hard and soft tissue
change
Three studies (Yilmaz et al. 1998; Schropp

et al. 2003 and Oghli & Steveling 2010)
reported data on horizontal hard and soft tissue changes. The studies by Yilmaz et al.
(1998) and Schropp et al. (2003) had a followup of up to 12 months; both studies exhib 2011 John Wiley & Sons A/S
ited a trend where there was a rapid reduction in first 3 months and gradual change
from thereafter, up to 12 months. Weighted
mean reduction showed this change to be
1.3 mm at 3 months and 5.1 mm at
12 months.
Vertical vs. horizontal combined hard and soft
change
Hard and soft tissue showed a combined horizontal reduction of 0.13.8 mm and 5.1 mm
at 3 and 6 months respectively. Correspondingly, in the vertical dimension, this change
was between 0.1 and 0.8 mm reduction at
3 months, and 0.1 mm gain to 0.9 mm
reduction at 6 months. Overall, the demonstrated horizontal change was more substantial than the vertical change.
Combined hard and soft tissue change vs. hard
tissue change only
In the horizontal dimension, the combined

hard and soft tissue reduction was 5.1 mm at
6 months, while the corresponding hard
tissue reduction was between 2.46 and
4.56 mm, with a weighted mean reduction of
3.79 mm.
Hence, at 6 months post-extraction, the
combined hard and soft tissues demonstrated
a tendency towards a more substantial reduction than hard tissue only; this observation is
not corroborated in the vertical aspect.
In the vertical dimension, when considering only hard tissue change (loss of 0.4
1.5 mm at 6 months), the magnitude of this
change was greater than that of the hard and
soft tissues combined (0.1 mm gain to
0.9 mm reduction at 6 months). A plausible
explanation might be that the increase in soft
tissue thickness (gain of 2.1 mm occlusally
vs. gain of only 0.40.5 mm on buccal/lingual) compensated for the reduction in hard
tissue height.
Possible factors affecting dimensional change
after tooth extraction
Flap vs. flapless
Using a canine model, Fickl et al. (2008a)

demonstrated that there was significant difference of the extent of bone resorption
between flap and flapless extractions. The
flapless group had lower extent of resorption
compared to the flap group. Blanco et al.
(2008) also showed similar trend in another
study, although the study was investigating
ridge alterations after immediate implants
with or without flap. However, Araujo &
Lindhe (2009) found that the differences
between the flap and flapless groups in their
study were negligible after 6 months. Hence,

raising a flap during extraction may only
affect the short-term dimensional alterations
of the alveolar ridge.
Overeruption of adjacent teeth
Mizutani & Ishihata (1976) found that the

over-eruption of teeth adjacent to the extraction socket affected the overall dimensional
change of ridge. The vertical alveolar ridge
height in this study decreased slightly initially, followed by a gradual increase later on,
which negated the previous reduction or even
surpassed the amount of resorption to result
in a net gain. The study speculated that the
over-eruption of teeth adjacent to extraction
sites might have affected the pattern of
dimensional change observed.
Smoking
Smoking may affect the extent of vertical

reduction of the alveolar ridge after extraction. Saldanha et al. (2006) showed that
there was a significant difference in dimensional reduction between smoking and nonsmoking groups. There was vertical alveolar
ridge reduction of 1.5 mm in smokers and
1.0 mm in non-smokers, 6 months postextraction.
Single-rooted vs. multiple-rooted teeth
Moya-Villaescusa & Sanchez-Perez (2010)

study showed there was no significant difference in vertical dimensional change between
single-rooted (4.16 mm loss) and multi-rooted
teeth (4.48 mm loss), although there was a
tendency that multi-rooted teeth exhibited
greater resorption of the alveolar ridge.
Chlorhexidine
Rinsing with 15 ml of 0.12% chlorhexidine

digluconate mouthrinse twice daily for
1 month, starting 2 days after extraction may
have some effect on the observed vertical
change of the mesial and distal bone. Bragger
et al. (1994) showed that patients rinsing for
1 month with a placebo solution lost almost
1 mm of bone height over a 6-month period
after extraction, while in patients rinsing
with the chlorhexidine solution, the crestal
alveolar bone level was maintained.
Immediate denture
Carlsson & Persson (1967) showed that there

was no significant difference in alveolar
dimensional change between patients with
immediate or conventional dentures in the
long-term. Take note, however, that the
usage of immediate dentures had a tendency
to affect dimensional change in short-term,
15 |
but the effect would be negligible after

2 years post-extraction.
Bone resorption pattern after 12 months
Only one study (Carlsson & Persson 1967)

followed dimensional changes in human
alveolar ridge for up to 5 years. This study
displayed a similar pattern where there was a
relatively rapid reduction in the first
6 months in both vertical and horizontal
dimension, followed by a gradual reduction
thereafter; the reduction continued at a
steady rate for up to 5 years. This finding
could suggest that bone resorption will continue throughout life once the teeth are
extracted. Take note, however, that all the
patients in this study wore complete dentures; dentures were inserted 2 months after
extractions in the conventional group and
immediately after extractions in the immediate group. We can speculate that the usage of
removable complete dentures may also affect
the pattern of resorption of the alveolar tissues.
Conclusions
In conclusion, the studies included in this
review demonstrated that horizontal bone
loss (2963%, 2.464.56 mm, weighted mean
3.79 mm at 6 months) was more substantial
than vertical bone loss (1122%, 0.81.5 mm,
weighted mean 1.24 mm at 6 months) after
tooth extraction. The buccal aspect generally
displayed more resorption than the lingual/
palatal aspect. There is an observed resorption pattern of rapid reduction in the first 3
6 months, followed by gradual reduction
thereafter, throughout life.
Soft tissue on the buccal and lingual surfaces of the alveolar ridge has a tendency to
increase in thickness after extraction, as
reported in one study; the significance of this
finding is as yet unknown. The same study
also documented that 6 months post-extraction, a soft tissue cover of 2.1 mm in thickness developed over the original socket; this
soft tissue thickness that develops post-
extraction may mask the real extent of hard

tissue resorption and impact on the overall
outcome of any reconstructive efforts, especially with regard to aesthetics. However,
more studies might be required to arrive at a
more definitive value of soft tissue changes
post-extraction, and clarify the influence of
this change.
Overall, dimensional alterations of the
alveolar hard and soft tissues can be quite
extensive, and an astute clinician will do
well to understand the pattern and sequelae
of these changes, to arrive at predictable
treatment outcomes
Acknowledgement:
This study has

been made possible by an educational grant
of the Osteology Foundation, Lucerne,
Switzerland.
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Oghli, A.A. & Steveling, H. (2010) Ridge preservation following tooth extraction: a comparison
between atraumatic extraction and socket seal
surgery. Quintessence International 41: 605609.
Pelegrine, A.A., da Costa, C.E., Correa, M.E. &
Marques, J.F. Jr (2010) Clinical and histomorpho-
metric evaluation of extraction sockets treated

with an autologous bone marrow graft. Clinical
Rasperini, G., Canullo, L., Dellavia, C., Pellegrini,
G. & Simion, M. (2010) Socket grafting in the
posterior maxilla reduces the need for sinus augmentation. International Journal of Periodontics
& Restorative Dentistry 30: 265273.
Rodd, H.D., Malhotra, R., OBrien, C.H., Elcock, C.,
Davidson, L.E. & North, S. (2007) Change in supporting tissue following loss of a permanent maxillary incisor in children. Dental Traumatology
23: 328332.
Saldanha, J.B., Casati, M.Z., Neto, F.H., Sallum, E.
A. & Nociti, F.H. Jr (2006) Smoking may affect
the alveolar process dimensions and radiographic
bone density in maxillary extraction sites: a prospective study in humans. Journal of Oral &
Schropp, L., Wenzel, A., Kostopoulos, L. & Karring,
T. (2003) Bone healing and soft tissue contour
changes following single-tooth extraction: a clinical and radiographic 12-month prospective study.
International Journal of Periodontics & Restorative Dentistry 23: 313323.
Serino, G., Biancu, S., Iezzi, G. & Piattelli, A.
(2003) Ridge preservation following tooth extraction using a polylactide and polyglycolide sponge
as space filler: a clinical and histological study in
humans. Clinical Oral Implants Research 14:
651658.
Yilmaz, S., Efeoglu, E. & Kilic, A.R. (1998) Alveolar
ridge reconstruction and/or preservation using
root form bioglass cones. Journal of Clinical Periodontology 25: 832839.
List of included articles:

Aimetti, M., Romano, F., Griga, F.B. & Godio, L.
(2009) Clinical and histologic healing of human
extraction sockets filled with calcium sulfate.
Barone, A., Aldini, N.N., Fini, M., Giardino, R.,
Calvo Guirado, J.L. & Covani, U. (2008) Xenograft
versus extraction alone for ridge preservation
after tooth removal: a clinical and histomorphometric study. Journal of Periodontology 79: 1370
1377.
Bragger, U., Schild, U. & Lang, N.P. (1994) Effect of
chlorhexidine (0.12%) rinses on periodontal tissue
healing after tooth extraction. (II). Radiographic
parameters. Journal of Clinical Periodontology
21: 422430.
Camargo, P.M., Lekovic, V., Weinlaender, M., Klokkevold, P.R., Kenney, E.B., Dimitrijevic, B.,
Nadic, M., Jancovic, S. & Orsini, M. (2000) Influence of bioactive glass on changes in alveolar process dimensions after exodontia. Oral Surgery
Oral Medicine Oral Pathology Oral Radiology &
Endodontology 90: 581586.
Carlsson, G.E. & Persson, G. (1967) Morphologic
changes of the mandible after extraction and
wearing of dentures. A longitudinal, clinical, and
x-ray cephalometric study covering 5 years. Odontologisk Revy 18: 2754.
Crespi, R., Cappare, P. & Gherlone, E. (2009) Magnesium-enriched hydroxyapatite compared to calcium sulfate in the healing of human extraction
evaluation at 3 months. Journal of Periodontology 80: 210218.
Fiorellini, J.P., Howell, T.H., Cochran, D., Malmquist, J., Lilly, L.C., Spagnoli, D., Toljanic, J.,
List of excluded full text articles and the reason for exclusion:
Agbaje, J.O., Jacobs, R., Michiels, K., Abu-Taa, M.
& van Steenberghe, D. (2009) Bone healing after
dental extractions in irradiated patients: a pilot
study on a novel technique for volume assessment of healing tooth sockets. Clinical Oral
Investigations 13: 257261.
Exclusion criteria: reported parameters not

relevant or not useful.
17 |
Ahn, J.J. & Shin, H.I. (2008) Bone tissue formation

in extraction sockets from sites with advanced
periodontal disease: a histomorphometric study
in humans. The International Journal of Oral &
Maxillofacial Implants 23: 11331138.
Exclusion criteria: no measurements of

alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Alissa, R., Esposito, M., Horner, K. & Oliver, R.
(2010) The influence of platelet-rich plasma on
the healing of extraction sockets: an explorative
randomised clinical trial. European Journal of
Oral Implantology 3: 121134.

Altundal, H. & Guvener, O. (2004) The effect of
alendronate on resorption of the alveolar bone following tooth extraction. The International Journal of Oral & Maxillofacial Surgery 33: 286293.

Alves-Rezende, M.C. & Okamoto, T. (1997) Effects
of fibrin adhesive material (tissucol) on alveolar
healing in rats under stress. Brazilian Dental
Journal 8: 1319.

histology only).
Amemori, H. (1966) An experimental study of
changes in the form of the mandible after extraction of lower posterior teeth. I. The areal change
of mandibular frontal sections.. Bulletin of Tokyo
Medical & Dental University 13: 5974.
Exclusion criteria: no baseline data available for comparison, thus unable to arrive at
an estimate of dimensional change over time.
Araujo, M.G. & Lindhe, J. (2009b) Ridge preservation with the use of bio-oss collagen: a 6-month
study in the dog. Clinical Oral Implants
Research 20: 433440.
Exclusion criteria: sample did not include

untreated/undisturbed extraction sockets left
to heal spontaneously.
Araujo, M.G., Sukekava, F., Wennstrom, J.L. &
Lindhe, J. (2005) Ridge alterations following
implant placement in fresh extraction sockets: an
experimental study in the dog. Journal of Clin

Ashman, A. & Bruins, P. (1985) Prevention of alveolar bone loss postextraction with htr grafting
material. Oral Surgery Oral Medicine & Oral
Pathology 60: 146153.
Exclusion criteria: descriptive report on

procedure/technique; commentary.
Ashman, A. & Bruins, P. (1987) Prevention of alveolar bone loss postextraction with htr polymer
grafting material. Journal of Oral Implantology
13: 270281.

Bahat, O., Deeb, C., Golden, T. & Komarnyckij, O.
(1987) Preservation of ridges utilizing hydroxyapatite. International Journal of Periodontics &
Restorative Dentistry 7: 3441.
Exclusion criteria: study carried out on animals.

Anitua, E. (1999) Plasma rich in growth factors: preliminary results of use in the preparation of
future sites for implants. The International Journal of Oral & Maxillofacial Implants 14: 529
535.
Bergstedt, H., Wictorin, L. & Lundquist, G. (1973)

Transplantation of bone treated with ethylenediamine into tooth sockets in immediate denture
patients. Sven Tandlak Tidskr 66: 3948.

histology only).
Araujo, M., Linder, E., Wennstrom, J. & Lindhe, J.
(2008) The influence of bio-oss collagen on healing of an extraction socket: an experimental
study in the dog. International Journal of Periodontics & Restorative Dentistry 28: 123135.

Araujo, M.G. & Lindhe, J. (2005) Dimensional ridge
alterations following tooth extraction. An experimental study in the dog.. Journal of Clinical Periodontology 32: 212218.
Exclusion criteria: only measured relative

difference in height between buccal and lingual plates of the alveolus.
Araujo, M.G. & Lindhe, J. (2009a) Ridge alterations
following tooth extraction with and without flap
elevation: an experimental study in the dog. Clinical Oral Implants Research 20: 545549.
18 |
Exclusion criteria: study subjects had

immediate dentures after extraction, hence
they did not have undisturbed healing postextraction.
Berkovitz, B.K. (1971) The healing process in the
incisor tooth socket of the rat following root
resection and exfoliation. Archives of Oral Biology 16: 10451054.

histology only).
Bianchi, J., Fiorellini, J.P., Howell, T.H., Sekler, J.,
Curtin, H., Nevins, M.L. & Friedland, B. (2004)
Measuring the efficacy of rhbmp-2 to regenerate
bone: a radiographic study using a commercially
available software program. International Journal
of Periodontics & Restorative Dentistry 24: 579
587.

Boyes-Varley, J.G., Cleaton-Jones, P.E. & Lownie, J.
F. (1988) Effect of a topical drug combination on
the early healing of extraction sockets in the ver-
vet monkey. The International Journal of Oral &


alveolar dimensional changes (e.g. description
histology only).
Boyne, P.J. (1995) Use of htr in tooth extraction
sockets to maintain alveolar ridge height and
increase concentration of alveolar bone matrix.
General Dentistry 43: 470473.

Brandao, A.C., Brentegani, L.G., Novaes, A.B. Jr,
Grisi, M.F., Souza, S.L., Taba Junior, M. & Salata,
L.A. (2002) Histomorphometric analysis of rat
alveolar wound healing with hydroxyapatite alone
or associated to bmps. Brazilian Dental Journal
13: 147154.

Cardaropoli, G., Araujo, M., Hayacibara, R., Sukekava, F. & Lindhe, J. (2005) Healing of extraction
sockets and surgically produced augmented and
non-augmented defects in the alveolar ridge. An
experimental study in the dog.. Journal of Clinical Periodontology 32: 435440.

histology only).
Carlsson, G.E., Thilander, H. & Hedegard, B. (1967)
Histologic changes in the upper alveolar process
after extractions with or without insertion of an
immediate full denture. Acta Odontolologica
Scandinavica 25: 2143.

histology only).
Carmagnola, D., Adriaens, P. & Berglundh, T.
(2003) Healing of human extraction sockets filled
with bio-oss. Clinical Oral Implants Research
14: 137143.

histology only).
Dayan, D., Bodner, L. & Horowitz, I. (1992) Effect
of salivary gland hypofunction on the healing of
extraction wounds: a histomorphometric study in
rats. Journal of Oral & Maxillofacial Surgery 50:
354358.

histology only).
Fickl, S., Zuhr, O., Wachtel, H., Bolz, W. & Huerzeler, M. (2008b) Tissue alterations after tooth
extraction with and without surgical trauma: a
volumetric study in the beagle dog. Journal of

Fickl, S., Zuhr, O., Wachtel, H., Stappert, C.F.,
Stein, J.M. & Hurzeler, M.B. (2008c) Dimensional
changes of the alveolar ridge contour after different socket preservation techniques. Journal of

Fickl, S., Zuhr, O., Wachtel, H., Bolz, W. & Huerzeler, M.B. (2008c) Hard tissue alterations after
socket preservation: an experimental study in the
beagle dog. Clinical Oral Implants Research 19:
11111118.
Gauthier, O., Boix, D., Grimandi, G., Aguado, E.,
Bouler, J.M., Weiss, P. & Daculsi, G. (1999) A
new injectable calcium phosphate biomaterial for
immediate bone filling of extraction sockets: a
preliminary study in dogs. Journal of Periodontology 70: 375383.

Gorustovich, A., Veinsten, F., Costa, O.R. & Guglielmotti, M.B. (2004) Histomorphometric evaluation of the effect of bovine collagen granules on
bone healing. An experimental study in rats. Acta
Odontologica Latinoamericana 17: 913.

Green, L.J., Gong, J.K. & Neiders, M.E. (1969) Relationship between sr85 uptake and histological
changes during healing in dental extraction wounds
in rats. Archives of Oral Biology 14: 865872.

histology only).
Guglielmotti, M.B. & Cabrini, R.L. (1985) Alveolar
wound healing and ridge remodeling after tooth
extraction in the rat: a histologic, radiographic,
and histometric study. Journal of Oral & Maxillofacial Surgery 43: 359364.

Guglielmotti, M.B., Ubios, A.M. & Cabrini, R.L.
(1985) Alveolar wound healing alteration under
uranyl nitrate intoxication. Journal of Oral
Pathology 14: 565572.

Guglielmotti, M.B., Ubios, A.M. & Cabrini, R.L.
(1986) Alveolar wound healing after x-irradiation:
a histologic, radiographic, and histometric study.
Journal of Oral & Maxillofacial Surgery 44: 972
976.
Hahn, E., Sonis, S., Gallagher, G. & Atwood, D.
(1988) Preservation of the alveolar ridge with
hydroxyapatite-collagen implants in rats. Journal
of Prosthetic Dentistry 60: 729734.
wound healing in rats. Acta Odontologica Scandinavica 30: 511522.
socket healing in the rat. Archives of Oral Biology 18: 12831289.

histology only).

histology only).
Horn, Y., Sela, M.N., Shlomi, B., Ulmansky, M. &

Sela, J. (1979) Effect of irradiation-timing on the
initial socket healing in rats. International Journal of Oral Surgery 8: 457461.
Lindeboom, J.A., Tjiook, Y. & Kroon, F.H. (2006)

Immediate placement of implants in periapical
infected sites: a prospective randomized study in
50 patients. Oral Surgery Oral Medicine Oral
Pathology Oral Radiology & Endodontology 101:
705710.

histology only).
Hsieh, Y.D., Devlin, H. & McCord, F. (1995) The
effect of ovariectomy on the healing tooth socket
of the rat. Archives of Oral Biology 40: 529531.
Huebsch, R.F. & Hansen, L.S. (1969) A histopathologic study of extraction wounds in dogs. Oral
Surgery Oral Medicine & Oral Pathology 28: 187
196.

histology only).
Iino, G., Nishimura, K., Omura, K. & Kasugai, S.
(2008) Effects of prostaglandin e1 application on
rat incisal sockets. The International Journal of
Oral & Maxillofacial Implants 23: 835840.

Iizuka, T., Miller, S.C. & Marks, S.C. Jr (1992)
Alveolar bone remodeling after tooth extraction
in normal and osteopetrotic (ia) rats. Journal of
Oral Pathology & Medicine 21: 150155.

Indovina, A. Jr & Block, M.S. (2002) Comparison of 3
bone substitutes in canine extraction sites. Journal
of Oral & Maxillofacial Surgery 60: 5358.

Kangvonkit, P., Matukas, V.J. & Castleberry, D.J.
(1986) Clinical evaluation of durapatite submerged-root implants for alveolar bone preservation. The International Journal of Oral &

Lavelle, C.L. (1985) Preliminary study of mandibular shape after tooth loss. Journal of Prosthetic
Dentistry 53: 726730.

histology only).
Hars, E. & Massler, M. (1972) Effects of fluorides,

cortico-steroids and tetracyclines on extraction
Librus, H., Pietrokovski, J., Ulmanski, M. & Gedalia, I. (1973) The effect of fluoride on molar

Loo, W.D. (1968) Ridge preservation with immediate treatment dentures. Journal of Prosthetic
Dentistry 19: 511.

Luvizuto, E.R., Queiroz, T.P., Dias, S.M., Okamoto,
T., Dornelles, R.C., Garcia, I.R. Jr & Okamoto, R.
(2010) Histomorphometric analysis and immunolocalization of rankl and opg during the alveolar
healing process in female ovariectomized rats
treated with oestrogen or raloxifene. Archives of
Oral Biology 55: 5259.

histology only).
Magro Filho, O. & de Carvalho, A.C. (1990) Application of propolis to dental sockets and skin
wounds. Journal of Nihon University School of
Dentistry 32: 413.

histology only).
Magro-Ernica, N., Magro-Filho, O. & Rangel-Garcia,
I. (2003) Histologic study of use of microfibrillar
collagen hemostat in rat dental sockets. Brazilian
Dental Journal 14: 1215.

Mathai, J.K., Chandra, S., Nair, K.V. & Nambiar, K.
K. (1989) Tricalcium phosphate ceramic as immediate root implants for the maintenance of alveolar bone in partially edentulous mandibular jaws.
A clinical study. Australian Dental Journal 34:
421426.

Matsumoto, M. (1968) Changes in residual ridge of
the mandible after extraction and wearing extension saddle type of removable partial dentures. (a
longitudinal, clinical and roentgenographic investigation). Bulletin of Tokyo Medical & Dental
University 15: 6789.
Exclusion criteria: length of observation

period not reported.
Michael, C.G. & Barsoum, W.M. (1976) Comparing
ridge resorption with various surgical techniques
in immediate dentures. Journal of Prosthetic
Dentisty 35: 142155.
19 |

Minsk, L. (2005) Extraction-site ridge preservation.
Compendium of Continuing Education in Dentistry 26: 272.

Mizutani, H. & Ishihata, N. (1976) Decrease and
increase in residual ridges after extraction of
teeth in monkeys (part I). Bulletin of Tokyo Medical & Dental University 23: 157168.

Nevins, M., Camelo, M., De Paoli, S., Friedland, B.,
Schenk, R.K., Parma-Benfenati, S., Simion, M.,
Tinti, C. & Wagenberg, B. (2006) A study of the
fate of the buccal wall of extraction sockets of
teeth with prominent roots. International Journal
of Periodontics & Restorative Dentistry 26: 19
29.

Nevins, M.L., Camelo, M., Schupbach, P., Kim, D.
M., Camelo, J.M. & Nevins, M. (2009) Human histologic evaluation of mineralized collagen bone
substitute and recombinant platelet-derived
growth factor-bb to create bone for implant placement in extraction socket defects at 4 and
6 months: a case series. International Journal of
Periodontics & Restorative Dentistry 29: 129139.

Normando, A.D., Maia, F.A., Ursi, W.J. & Simone,
J.L. (2010) Dentoalveolar changes after unilateral
extractions of mandibular first molars and their
influence on third molar development and position. World Journal of Orthodontics 11: 5560.

Olson, H.M. & Hagen, A. (1982) Inhibition of postextraction alveolar ridge resorption in rats by dichloromethane diphosphonate. Journal of Periodontal Research 17: 669674.

Olson, R.A., Roberts, D.L. & Osbon, D.B. (1982) A
comparative study of polylactic acid, gelfoam,
and surgicel in healing extraction sites. Oral Surgery Oral Medicine & Oral Pathology 53: 441
449.

histology only).
Oltramari, P.V., Navarro Rde, L., Henriques, J.F.,
Taga, R., Cestari, T.M., Janson, G. & Granjeiro, J.
M. (2007) Evaluation of bone height and bone
density after tooth extraction: an experimental
study in minipigs. Oral Surgery Oral Medicine
Oral Pathology Oral Radiology & Endodontology
104: 916.
20 |
tite root implants. Oral Surgery Oral Medicine &

Oral Pathology 58: 511521.
Ortega, K.L., Rezende, N.P., Araujo, N.S. & Magalhaes, M.H. (2007) Effect of a topical antimicrobial paste on healing after extraction of molars in
hiv positive patients: randomised controlled clinical trial. British Journal of Oral & Maxillofacial
Surgery 45: 2729.

histology only).

Pessoa, R.S., Oliveira, S.R., Menezes, H.H. & de
Magalhaes, D. (2009) Effects of platelet-rich
plasma on healing of alveolar socket: split-mouth
histological and histometric evaluation in cebus
apella monkeys. Indian Journal of Dental
Research 20: 442447.
Pietrokovski, J. (1967) Healing of the socket
following tooth extraction. Alpha Omegan 60:
126129.

histology only).
Pietrokovski, J. & Massler, M. (1967a) Alveolar
ridge resorption following tooth extraction. Journal of Prosthetic Dentistry 17: 2127.
Exclusion criteria: length of observation

period not reported.
Pietrokovski, J. & Massler, M. (1967b) Ridge remodeling after tooth extraction in rats. Journal of
Dental Research 46: 222231.

histology only).
Pietrokovski, J. & Massler, M. (1971) Residual ridge
remodeling after tooth extraction in monkeys.
Journal of Prosthetic Dentistry 26: 119129.

histology only).
Pinto, J.R., Bosco, A.F., Okamoto, T., Guerra, J.B. &
Piza, I.G. (2002) Effects of nicotine on the healing
of extraction sockets in rats. A histological study.
Brazilian Dental Journal 13: 39.

histology only).
Puia, S.A., Renou, S.J., Rey, E.A., Guglielmotti, M.
B. & Bozzini, C.E. (2009) Effect of bismuth subgallate (a hemostatic agent) on bone repair; a histologic, radiographic and histomorphometric
study in rats. The International Journal of Oral
& Maxillofacial Surgery 38: 785789.

Quinn, J.H. & Kent, J.N. (1984) Alveolar ridge
maintenance with solid nonporous hydroxylapa-
Richardson, A. (1965) The pattern of alveolar bone

resorption following extraction of anterior teeth.
Dental Practitioner & Dental Record 16: 7780.

Rothamel, D., Schwarz, F., Herten, M., Engelhardt,
E., Donath, K., Kuehn, P. & Becker, J. (2008)
Dimensional ridge alterations following socket
preservation using a nanocrystalline hydroxyapatite paste: a histomorphometrical study in dogs.
The International Journal of Oral & Maxillofacial Surgery 37: 741747.
Sattayasanskul, W., Brook, I.M. & Lamb, D.J. (1988)
Dense hydroxyapatite root replica implantation:
measurement of mandibular ridge preservation.

Scheer, P. & Boyne, P.J. (1987) Maintenance of alveolar bone through implantation of bone graft substitutes in tooth extraction sockets. Journal of
the American Dental Association 114: 594597.

Sclar, A.G. (1999) Preserving alveolar ridge anatomy
following tooth removal in conjunction with
immediate implant placement. The bio-col technique. Atlas of the Oral & Maxillofacial Surgery
Clinics of North America 7: 3959.

Serino, G., Rao, W., Iezzi, G. & Piattelli, A. (2008)
Polylactide and polyglycolide sponge used in
human extraction sockets: bone formation following 3 months after its application. Clinical

histology only).
Sharan, A. & Madjar, D. (2008) Maxillary sinus
pneumatization following extractions: a radiographic study. The International Journal of Oral
& Maxillofacial Implants 23: 4856.

histology only).
Shi, B., Zhou, Y., Wang, Y.N. & Cheng, X.R. (2007)
Alveolar ridge preservation prior to implant placement with surgical-grade calcium sulfate and
platelet-rich plasma: a pilot study in a canine
model. The International Journal of Oral & Maxillofacial Implants 22: 656665.

Smith, N. (1974) A comparative histological and
radiographic study of extraction socket healing in
the rat. Australian Dental Journal 19: 250254.

histology only).
Teofilo, J.M., Brentegani, L.G. & Carvalho, T.L.
(2001) A histometric study in rats of the effect of
the calcium antagonist amlodipine on bone healing after tooth extraction. Archives of Oral Biology 46: 375379.

Teofilo, J.M., Leonel, D.V. & Lamano, T. (2010)

Cola beverage consumption delays alveolar bone
healing: a histometric study in rats. Brazilian
Oral Research 24: 177181.

histology only).
Thilander, H. & Astrand, P. (1973) The effect of tetracyclines on socket healing. Acta Odontologica
Scandinavica 31: 131139.

histology only).
Ubios, A.M., Jares Furno, G. & Guglielmotti, M.B.
(1991) Effect of calcitonin on alveolar wound
healing. Journal of Oral Pathology & Medicine
20: 322324.

Wu, Z., Liu, C., Zang, G. & Sun, H. (2008) The
effect of simvastatin on remodelling of the alveolar bone following tooth extraction. The International Journal of Oral & Maxillofacial Surgery
37: 170176.

Yugoshi, L.I., Sala, M.A., Brentegani, L.G. & Lamano Carvalho, T.L. (2002) Histometric study of
socket healing after tooth extraction in rats treated with diclofenac. Brazilian Dental Journal 13:
9296.

21 |

A RS of Post-Extractional Alveolar Hard and Soft Tissue Dimensional Changes

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Wah Lay Tan

A systematic review of post-extractional alveolar hard and soft tissue

teeth, resorption, soft tissue, systematic review

To cite this article:

2011 John Wiley & Sons A/S

The periodontium is an important structure

tion or extraction of the tooth. Subsequent to

Tan et al Dimensional tissue changes post extraction

and compositional changes in the overlying

Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/121

that alveolar bone loss can be quite marked

Material and methods

What is the magnitude of dimensional

A comprehensive and systematic electronic

(<[MeSH terms/all subheadings] Bone

Studies were included if they were published

(<[MeSH terms/all subheadings] Tooth

Screening was performed independently by

Tan et al Dimensional tissue changes post extraction

Publications excluded on the basis of title

Register of Controlled Trials (CENTRAL).

Publications included based on the handsearch and bibliography search of

Publications included based on the

Studies included in the

Fig. 1. Search strategy. Post-extraction dimensional changes.

Of the 104 full-text articles examined, 85

Table 1. Studies failing to meet inclusion criteria

Rationale for exclusion

Reported parameters not relevant or not useful

2011 John Wiley & Sons A/S

Length of observation period not reported

Study subjects had immediate dentures after extraction,

Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/121

Tan et al Dimensional tissue changes post extraction

of both soft and hard tissues of the alveolar

Assessment of study quality was performed

For the weighted mean of the list of data for

The weighted mean in this case is:

Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/121

Statistical heterogeneity between all the

The P-value was then calculated for the Q

where, I2 = 0% to 40% would indicate

including molar extraction sites and one

There were a total of 20 studies addressing

Vertical and horizontal linear hard tissue

Tan et al Dimensional tissue changes post extraction

Table 2. Cochrane Collaborations tool for assessing risk of bias

Bragger et al. (1994)

Adequate sequence generation

Free of selective reporting

Free of other sources of bias

Lekovic et al. (1997)

Lekovic et al. (1998)

Adequate sequence generation

Incomplete outcome data addressed

Free of selective reporting

Insufficient information about sequence generation

Camargo et al. (2000)

Iasella et al. (2003)

Controlled clinical trial

Fiorellini et al. (2005)

Quote randomly selected

Quote cohorts of 40 patient