Monica Calasans-Maia A randomized controlled clinical trial

Rodrigo Resende
Gustavo Fernandes
to evaluate a new xenograft for
Jose Calasans-Maia alveolar socket preservation
Adriana Terezinha Alves
Jos
e Mauro Granjeiro

Authors’ affiliations: Key words: bone implant interactions, bone substitutes, clinical research, clinical trials
Monica Calasans-Maia, Rodrigo Resende,
Department of Oral Surgery, Fluminense Federal
University, Niteroi, Brazil Abstract
Gustavo Fernandes, Cell and Molecular Biology Objective: The aim of this clinical trial was to compare the effect of Bio-Ossâ and a new bovine
Department, Fluminense Federal University,
xenograft (Osseusâ) in alveolar sockets after a 24-week healing period.
Niteroi, Brazil
Jose Calasans-Maia, Department of Orthodontics, Materials and methods: A total of 20 adult volunteers ages 30–60 were subjected to single tooth
Fluminense Federal University, Nova Friburgo, extraction. A tooth extraction was performed at the baseline. All sites were randomly allocated to
Brazil
two test groups (TG1: grafted using a new bovine xenograft, Osseusâ, and TG2: grafted using
Adriana Terezinha Alves, Department of Oral
Pathology, Gama Filho University, Rio de Janeiro, commercially available bovine xenograft-Bio-Ossâ). Six months later, a sample of the grafted area
Brazil was obtained and implants were inserted in the same site. Histological sections were examined
Jos
e Mauro Granjeiro, Fluminense Federal
University, Niteroi, Brazil focusing on the presence of fibrous connective tissue (CT), and newly formed bone in direct
Bioengineering Program, National Institute of contact with the graft. The HE-stained sections were subjected to histomorphometrical evaluation
Metrology Standardization and Industrial Quality, using Image Pro-Plusâ software (Release 7.0). The definitive crown was placed 3 months later.
Duque de Caxias, Brazil
Results: Upon completion of the study, no patients were removed from the study and all inserted
Corresponding author: implants (10 in each group) were eventually integrated. After 6 months, in the TG1, the mean
Monica Calasans-Maia value of new bone formation was 33.7 (7.1), for CT was 32.3 (8.9) and for the remaining
Department of Oral Surgery
Fluminense Federal University biomaterial was 10.7 (16.2). In the TG2, the mean value of new bone formation was 19.3 (22.6),
Rua Mario Santos Braga of the CT was 49.9 (14.1) and of the remaining biomaterial was 22.6 (7.9).
30. Centro
Conclusions: No statistically significant difference was observed between TG1 and TG2 after
Niteroi
Rio de janeiro 6 months (P > 0.05), and both biomaterials afforded a more favorable implant position.
CEP: 24020-140
Brazil
e-mail: monicacalasansmaia@gmail.com
The aim of implant dentistry is to restore (Schropp et al. 2003), primarily due to the
missing or extracted teeth by placing implants resorption of the buccal bone plate (Ara
ujo &
in anatomical, esthetical, and long-term Lindhe 2011). The ridge preservation proce-
functional restorative positions (Kutkut et al. dures facilitate the preservation of the alveo-
2012). The amount of hard tissue resorption lar architecture to prevent hard and soft
following tooth extraction occasionally tissue collapse and minimize or eliminate
involves prosthetically driven implant place- the necessity for future augmentation proce-
ment; therefore, the development of ridge dures (Tan et al. 2012). Many graft materials,
preservation techniques that result in less such as autogenous bone grafts (Pelegrine
alveolar bone loss is of great interest (Sisti et al. 2010), allografts (Wood et al. 2012;
et al. 2012). Extraction socket wound healing xenografts (Calasans-Maia et al. 2009; Fernan-
is characterized by resorption of the alveolar des et al. 2011; Spinato et al. 2012; Festa
bone at the extraction site, which reduces et al. 2011), and alloplasts (Gonshor et al.
the bone volume available for implant place- 2011; Ruga et al. 2011; Brkovic et al. 2012),
ment. Major changes in the extraction socket have been used to maintain the dimensions
occur during the first year after tooth extrac- of the alveolar ridge after extraction in
Date: tion, with two-thirds of the bone loss occur- humans. Although some of these graft mate-
Accepted 3 July 2013 ring within the first 3 months (Schropp et al. rials preserved the post-extraction alveolar
To cite this article: 2003; Ara
ujo et al. 2008; Van der Weijden ridge dimensions to some extent, the quan-
Calasans-Maia M, Resende R, Fernandes G, Calasans-Maia J, et al. 2009), although dimensional changes tity and the quality of the bone tissue forma-
Alves AT, Granjeiro JM. A randomized controlled clinical
trial to evaluate a new xenograft for alveolar socket are observed up to 1 year after tooth extrac- tion in the socket varied and the presence
preservation.
tion, resulting in a 50% reduction in the buc- of these materials has often affected the
Clin. Oral Impl. Res. 00, 2013, 1–6
doi: 10.1111/clr.12237 colingual dimension of the alveolar ridge usual healing process (Heberer et al. 2011).

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
Calasans-Maia et al
Alveolar socket preservation with xenograft

Xenografts are obtained from a species that is Table 1. List of volunteer subjects investigated clinical photographs, study casts, and clinical
different from that of the recipients, and as Experimental examinations of the extraction sites. Sub-
osteoconductors, these grafts are predomi- Patient Gender Age Tooth groups sequently, the volunteers were provided
nantly made from the inorganic portion of 1 Female 30 46* 1 with detailed oral hygiene instructions, and
animal bone tissue (Granjeiro et al. 2005; 2 Female 52 37* 2 customized surgical splints were fabricated
3 Female 53 37* 2
Munhoz et al. 2006; Calasans-Maia et al. on the study casts for use in reentry proce-
4 Male 44 21‡ 1
2009; Accorsi-Mendoncßa et al. 2011; Zam- 5 Female 34 46* 2 dures to accurately obtain bone biopsies from
buzzi et al. 2012). The processing of bovine 6 Male 58 46‡ 1 the center of the grafted sockets.
bone results in two distinct types of materi- 7 Male 50 47‡ 2
8 Female 51 46* 2
als: inorganic and organic (predominantly col- 9 Female 34 36* 1
Surgical procedures
lagen type I). Inorganic material is free of 10 Female 34 16* 1 The following implant procedure was used at
proteins and cells because it only consists of 11 Female 53 22† 1 all extraction sites. The extraction was
12 Male 50 27‡ 2 performed under local anesthesia, without the
hydroxyapatite. The proteins are removed
13 Male 60 15† 2
through heat treatment at temperatures 14 Male 52 36‡ 2
elevation of a mucoperiosteal flap (Fig. 1a,b,
above 300°C or alkali treatment, followed by 15 Male 23 47* 2 Data S1). A periotome and the appropriate
neutralization, thus eliminating the risk of 16 Female 56 36† 1 dental forceps were used to minimize surgical
17 Female 48 26* 1
disease transmission. However, the bioab- trauma of the surrounding tissue. The thor-
18 Female 45 24† 1
sorption of these materials is reduced with 19 Female 33 34† 2 ough curettage of all soft tissue debris in the
increasing temperature (Wenz et al. 2001). 20 Female 31 36† 1 alveolus was performed during the extraction
Indeed, bovine materials obtained from Brazil *Extraction due to periodontal reason.
at all extraction sites to ensure the removal of
are regarded favorably, as Brazilian cattle are †
caries. all granulation tissue and stimulate bleeding
‡
free of spongiform encephalopathy (BSE or tooth/root fracture. from the osseous base to promote healing. A
mad cow disease). A new Brazilian bone sub- caliper (Dentaurumâ; Dentaurum Dental
stitute (Osseousâ; SIN, S~ao Paulo, SP, Brazil), size (10 subjects per group) was established Technology, Ispringen, Germany) was subse-
comprising an inorganic bovine bone matrix, in an attempt to minimize the publication quently used to measure the horizontal ridge
has been used as an alternative graft material bias (Vignoletti et al. 2012, Sisti et al. 2012). width (buccolingually) at the midpoint of the
for ridge preservation after tooth extraction alveolar crest using the mid-buccal and mid-
prior to implant placement. In previous in Patient selection palatal marks on the cervical bone surface as
vivo studies, we confirmed that this bovine All the patients were in general good health. published before (Mardas et al. 2011, Vigno-
xenograft is a biocompatible, bioabsorbable Any patient requiring one tooth extraction letti et al. 2012). After completion of the mea-
osteoconductor (Calasans-Maia et al. 2009; (hopeless tooth for periodontal, traumatic, or surements, the randomization envelope was
Jardelino-Lima et al. 2008). The aim of this caries reasons) and showing a bone defect opened and the assigned treatment test Osse-
study was to compare the effects of two between 3 and 5 mm at the buccal wall and ousâ (SIN) or control (Geistlich Biomaterials,
deproteinized bovine bone minerals in the no soft tissue recession was eligible for this Wollhusen, Switzerland) was revealed to the
healing of fresh extraction sockets using study according to specific exclusion and surgeon. The implant did not exceed the
clinical, histological, and histomorphometric inclusion criteria (Table 2). The recruitment height of the alveolar crest, and the site was
analyses. of the volunteers was carried out during visually inspected to ensure that the biomate-
6 months, and all volunteers were followed rial was saturated with blood (Fig. 1c). Pri-
up for a period of 12 months after prosthetic mary wound closure was performed following
Material and methods the elevation and rotation of the mucoperio-
rehabilitation. The volunteer subjects were
randomly assigned to the tests groups using steal flap (Fig. 1d,e). Postoperative antibiotic
This study was performed in compliance
an envelope system distribution provided by therapy (500-mg Azithromycin) was adminis-
with the principles outlined in the Declara-
the principal investigator. tered once a day for the first postoperative
tion of Helsinki concerning experimentation
week, and a disinfectant mouth rinse (0.12%
involving human subjects. Quality assess-
Presurgical procedures Chlorhexidine) was prescribed two times per
ment was carried out based on the RCT-
The medical and dental histories of the day, for the first two postoperative weeks.
checklist of the CONSORT-statements
patients were reviewed, and each patient Postoperative clinical evaluations of the
(Schulz et al. 2010). All procedures and mate-
was evaluated using periapical radiographs, patients were performed at 1, 7, 30, and
rials in the present study were approved
through the relevant independent committee
on the Ethics of Human Research of Flumin-
Table 2. Inclusion and exclusion criteria
ense Federal University (CEP/HUAP nº 118),
Inclusion criteria Exclusion criteria
and the volunteer subjects were informed
Age between 30 and 60 years Pregnancy or lactating period
about the study protocol and required to sign
Good general health Smoking
a consent form. Twenty patients (ten women Presence of a hopeless tooth requiring Chronic treatment with any medication known
and 10 men) participated in this randomized, extraction to affect oral status and bone turnover
controlled clinical trial, which took place in The extraction site would be suitable for Contraindicate surgical treatment
replacement by a dental implant Suffering from a known psychological disorder
the Dental Clinical Research Center at Flu-
Volunteer subjects had voluntarily signed
minense Federal University, Rio de Janeiro, the informed consent
Brazil (Table 1, Data S1). A minimum sample

2 | Clin. Oral Impl. Res. 0, 2013 / 1–6 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Calasans-Maia et al
Alveolar socket preservation with xenograft

(a) (b) Histological evaluation

Bone biopsy specimens (6 9 2 mm) obtained
from the grafted and ungrafted sockets were
fixed in 10% formalin for 2 days and subse-
quently decalcified in bone decalcification
solution (Alkimiaâ; Allkimia, Campinas, Bra-
zil) for 48 h. After routine processing, the tis-
sues were embedded in paraffin, sectioned
longitudinally into multiple 4lm-thick sec-
tions and stained with Hematoxylin and
Eosin (H&E) and Masson’s trichrome stain.
(d)
The two most central sections were obtained
from each specimen. For the qualitative and
morphologic analysis of the remodeling pro-
cess, the stained preparations were examined
under a light microscope (Zeiss Axioplan) at a
minimum 209 magnification and the entire
(c) section was evaluated. Ten digital images of
each section were acquired and used to trace
the areas identified as vital bone, biomaterial
particles, and connective tissue (CT)/other
non-bone components. Image analysis soft-
(f) ware (Image ProPlusâ, Release 7.0; MediaCy-
bernetics, Silver Spring, MD, USA) was used
to create individual layers of newly formed
bone, biomaterial particles, and CT/other non-
bone components, which were assessed by a
single observer blinded to the clinical data.

(e) Statistical analysis

The results were expressed as the means 
95%CI. The Mann–Whitney unpaired test were
(g) performed, considering significant differences if
P < 0.05.

Results

Clinical findings
Clinical healing was uneventful and free of
infection or symptoms in all volunteers from
both groups. Age and gender did not signifi-
cantly affect the clinical outcomes of this
Fig. 1. (a, b) Clinical and radiographic aspects of the hopeless tooth; (c) socket filled with the osseus xenograft; (d) study.
The flap was advanced coronally for primary closure; (e) radiographic aspect of the immediate area post grafting; (f, Almost complete soft tissue closure was
g) clinical and radiographic aspects at 6 months after grafting.
observed at 10 days after extraction in both
test groups. After 6 months of healing, when
90 days to determine the presence of compli- ridge width buccolingually. A core biopsy the bone specimen sample was obtained, both
cations, such as infection with inflammation, with a depth of 6 mm was obtained from the groups exhibited the same bone density and
wound dehiscence, or loss of graft material. center of the extraction site. A trephine bur showed the same resistance on trephine appli-
After 6 months, all sockets were evaluated (2 mm in diameter, SIN) was used to collect cation. Bone core samples were retrieved, and
through clinical and radiographic examination the biopsy specimen (Fig. 2a), followed by implants were placed in all sockets. The hori-
(Fig. 1f,g). dental implant placement according to the zontal ridge width (buccolingually) was mea-
manufacturer’s surgical protocol. Try-On or sured at the midpoint of the alveolar crest
Surgical reentry Strong implants (SIN) were used (Fig. 2b,c). using the mid-buccal and mid-palatal marks
At 24 weeks after extraction, the implants The mucoperiosteal flaps were closed with on the cervical bone crest before the tooth
were placed. A mucoperiosteal flap was interrupted sutures (Silk suture 4-0, Ethi- extraction and after 6 months of socket heal-
raised, and the site of extraction was identi- conâ). After 6 months, the implants were ing, and the results are showed in Table 3.
fied using a customized surgical splint. A successfully placed at all sites in the control Statically significant differences were not
caliper was used to measure the horizontal and test groups (Fig. 2d). observed between the groups.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 3 | Clin. Oral Impl. Res. 0, 2013 / 1–6
Calasans-Maia et al
Alveolar socket preservation with xenograft

(a) (c) (a)

(b) (b)

(d)

(c)

Fig. 4. Histomorphometric evaluation of the alveolar

Fig. 2. (a) Before implant installation a 2-mm specimen was removed using a trephine; (b, c) Clinical and sockets grafted with Bio-Ossâ and Osseusâ, consider-
radiographic images of the installed implant; (d) Prosthetic rehabilitation. ing the volume density of (a) newly-formed bone; (b)
connective tissue and (c) residual biomaterial particles.
Points in the plot represent all data, mean 95% of confi-
Histological observations dence interval (bars).

Table 3. Clinical outcomes with respect to Test sites

width in millimeters (standard deviation in
parentheses) One experienced blinded pathologist performed mation of new well-mineralized vital trabecu-
the histological evaluation. Histological slides lar bone was observed in all examined sections.
Change in
Tooth Group Baseline End width (mm) were prepared, and the cores were examined at The new bone showed trabecular organization,
209 and 409 magnification, revealing new with collagen fibers arranged in a meshwork
46 1 11 10.6 0.4
37 2 10 9.5 0.5 bone formation in all grafted sockets. The for- pattern and osteocytes randomly distributed
37 2 9.5 9.1 0.4
21 1 8.0 7.8 0.2
46 2 11.2 10.9 0.3
46 1 12.1 11.6 0.5 (a) (b)
47 2 12.3 12 0.3
46 2 11 10.4 0.6
36 1 11.5 11.1 0.4
16 1 11 10.8 0.2
22 1 7.0 6.8 0.2
27 2 12.0 11.7 0.3
15 2 6.5 6.3 0.2
36 2 11.5 11.2 0.3
47 2 12.4 12 0.4
36 1 11.8 11.6 0.2
26 1 12.1 12 0.1
24 1 9.0 8.8 0.2
34 2 7.0 6.4 0.6
Fig. 3. (a, b) Photomicrographs of the interface between xenograft and the new formed bone, Stain HE, 109 and
36 1 11.9 11.4 0.5
409 augmentation.

4 | Clin. Oral Impl. Res. 0, 2013 / 1–6 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

within the trabeculae in large spindle-shaped
lacunae (Fig. 3a,b). Loose fibrous tissue with
thin vessels filled the trabecular spaces. Dense,
trabecular bone patterns were observed in both
test groups. The overall mean value of the
newly formed vital bone area fraction for TG1
was 33.6% (7.1) and 19.3% (22.5) for TG2.
For TG1, the mean value of the newly formed
CT was 32.3% (8.8), and the mean value
of the remaining biomaterial was 10.6%
(16.2). For TG2, the mean value of the CT
was 49.9% (14.0), and the mean value of the
remaining biomaterial was 22.5% (7.9)
(Fig. 4).
Discussion
The present randomized clinical trial com-
pared two bovine xenografts (Bio-Ossâ and
Osseusâ) for the preservation of the alveolar
ridge dimensions following tooth extraction.
The clinical, histological, and histomorpho-
metrical evaluations did not show significant
differences between the two materials. In the
present study, biopsy specimens were
obtained and dental implants were placed
after a 6-month healing period. A healing
period of 6 months was selected because this
time point was used in two previously
reported systematic reviews. The first sys-
tematic review showed 29–63% horizontal
bone loss and 11–22% vertical bone loss
after 6 months following tooth extraction
and demonstrated rapid reductions in the
first 3–6 months, followed by gradual reduc-
tions in the dimensions (Tan et al. 2012).
The second systematic review showed a
3.8 mm horizontal reduction in width and a
1.24 mm vertical reduction in height of the
alveolar ridge within 6 months after tooth
extraction (H€ ammerle et al. 2012). These
studies demonstrated rapid reductions in the
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list.
Clin Oral Invest (2013) 17:341–363
DOI 10.1007/s00784-012-0758-5
REVIEW
Alveolar ridge preservation. A systematic review
Attila Horváth & Nikos Mardas & Luis André Mezzomo &
Ian G. Needleman & Nikos Donos
Received: 31 December 2011 / Accepted: 14 May 2012 / Published online: 20 July 2012
# Springer-Verlag 2012
Abstract
Objective The objective of this paper is to examine the
effect of alveolar ridge preservation (ARP) compared to
unassisted socket healing.
Methods Systematic review with electronic and hand search
was performed. Randomised controlled trials (RCT), controlled
clinical trials (CCT) and prospective cohort studies were
eligible.
Results Eight RCTs and six CCTs were identified. Clinical
heterogeneity did not allow for meta-analysis. Average change
in clinical alveolar ridge (AR) width varied between −1.0
and −3.5 ± 2.7 mm in ARP groups and between −2.5
and −4.6±0.3 mm in the controls, resulting in statistically
significantly smaller reduction in the ARP groups in five out
of seven studies. Mean change in clinical AR height varied
between +1.3±2.0 and −0.7±1.4 mm in the ARP groups and
between −0.8±1.6 and −3.6±1.5 mm in the controls. Height
reduction in the ARP groups was statistically significantly less
A. Horváth : N. Mardas : L. A. Mezzomo : I. G. Needleman :
N. Donos (*)
Unit of Periodontology, Department of Clinical Research,
UCL Eastman Dental Institute,
256 Gray’s Inn Road,
London WC1X 8LD, UK
e-mail: n.donos@ucl.ac.uk
A. Horváth
Department of Periodontology, Semmelweis University,
Budapest, Hungary
L. A. Mezzomo
Pontifical Catholic University of Rio Grande do Sul,
Porto Alegre, Brazil
I. G. Needleman
International Centre for Evidence-Based Oral Health,
UCL Eastman Dental Institute,
London, UK
in six out of eight studies. Histological analysis indicated
various degrees of new bone formation in both groups. Some
graft interfered with the healing. Two out of eight studies
reported statistically significantly more trabecular bone for-
mation in the ARP group. No superiority of one technique for
ARP could be identified; however, in certain cases guided
bone regeneration was most effective. Statistically, signifi-
cantly less augmentation at implant placement was needed
in the ARP group in three out of four studies. The strength of
evidence was moderate to low.
Conclusions Post-extraction resorption of the AR might be
limited, but cannot be eliminated by ARP, which at histolog-
ical level does not always promote new bone formation. RCTs
with unassisted socket healing and implant placement in the
ARP studies are needed to support clinical decision making.
Clinical relevance This systematic review reports not only on
the clinical and radiographic outcomes, but also evaluates the
histological appearance of the socket, along with site specific
factors, patient-reported outcomes, feasibility of implant
placement and strength of evidence, which will facilitate the
decision making process in the clinical practice.
Keywords Tooth extraction . Bone resorption . Implant site
development . Bone substitute . Bone regeneration .
Human histology
Introduction
Periodontal disease, periapical pathology and mechanical trau-
ma often result in bone loss prior to tooth removal [1]. Further-
more, traumatic extraction has also been associated with
additional loss of bone. In the healing phase after extraction,
alveolar bone undergoes additional atrophy as a result of the
natural remodelling process [2–7]. This begins immediately
342
after extraction and may result in up to 50 % resorption of the
alveolar ridge (AR) width even in 3 months [1]. Post-extraction
AR resorption may have an impact on dental implant place-
ment, since sufficient vertical and horizontal volume of alveolar
bone should ideally be present at the site of insertion [8].
Alveolar ridge preservation (ARP) procedures have been
introduced to maintain an acceptable ridge contour in areas
of aesthetic concern, as well as to prevent alveolar ridge
atrophy and maintain adequate dimensions of bone in order
to facilitate implant placement in prosthetically driven posi-
tions [9, 10]. Several methods have already been investigat-
ed for ARP in preclinical models [11–14] and clinical
studies, such as socket grafting with autogenous bone
[15], demineralised freeze-dried bone allograft (DFDBA)
[15–17], xenografts, like deproteinized bovine-bone
mineral (DBBM) [18], alloplasts [19] and bone morpho-
genic proteins (BMP) [20]. Guided bone regeneration
(GBR) with or without bone grafts has also been evaluated
[9, 10, 21–25].
Although some of the above bone substitutes were
able to limit the resorption of post-extraction alveolar
ridge up to a certain extent, the quality of the new
tissue in the socket varied broadly. The remnants of
the grafts often interfered with the normal healing pro-
cess in line with preclinical results [15–17, 26]. A
number of review articles on ARP have been published
in the last decade [27–32]. However, a systematic as-
sessment of the nature and quality of the newly formed
tissue alongside methodological quality and risk of bias
of the studies has not been carried out. Furthermore,
non-controlled prospective and retrospective studies as
well as case series were also included in most of the
previous reviews without the comparison to the control
group of unassisted socket healing [33–36].
Therefore, the objective of the present systematic review
was to investigate the effect of ridge preservation on the
residual alveolar ridge dimensions and on histological char-
acteristics, compared to unassisted socket healing.
Methods
Prior to commencement of the study, a detailed protocol was
developed and agreed upon by the authors based on the
Cochrane Collaboration guidelines and previous reviews
published by our group [37–41].
Focused question
Following tooth/root extraction in humans, what is the effect
of ridge preservation on the residual alveolar ridge dimension
and on histological characteristics, compared to unassisted
socket healing?
Clin Oral Invest (2013) 17:341–363
Definition
Whilst ‘socket preservation’ has widely been employed to
depict a certain procedure, we believe that the objective of
these interventions is to preserve the dimension of the AR.
Therefore, we have used the term ‘Alveolar Ridge Preser-
vation’ to define such procedures.
Types of studies
Longitudinal prospective studies were included, i.e. RCTs,
CCTs and cohort studies with control group.
Populations of studies
Healthy individuals, without any age limit, who underwent
any type of ridge preservation following permanent tooth
extraction, were included. Smokers and patients with history
of periodontal disease were not excluded. The minimum
number of subjects per group was five. However, no limit
was set for study follow-up period.
Types of interventions
Test groups
Studies reporting on any of the following types of interven-
tions were included: socket grafting (autograft, allograft,
xenograft, alloplastic materials); socket sealing (soft tissue
grafts); GBR (resorbable/non-resorbable barriers); biological
active materials (growth factors) and combinations of the
above techniques/materials.
Control groups
The control groups of the included studies comprised empty
sockets, i.e. unassisted socket healing.
Outcome variables
The primary outcome was the change in oro-facial (horizontal)
and apico-coronal (vertical) AR dimensions. Secondary out-
comes were the following: (1) change in buccal plate thickness;
(2) bone volume alteration following extraction; (3) complica-
tions; (4) histological healing characteristics; (5) site eligibility
for placement of an adequate size dental implant with or
without further augmentation; (6) patient-reported outcomes,
such as quality of life and (7) health economics.
Risk of bias and methodological quality assessment
In order to evaluate the methodological quality and risk of
bias of individual studies, we used a combination of
Clin Oral Invest (2013) 17:341–363
parameters from the Cochrane Collaboration and Consoli-
dated Standards of Reporting Trials (CONSORT) statement.
The following parameters were assessed and taken into
consideration in the final analysis: sample size calculation,
statement of eligibility criteria, ethics approval, informed
consent, baseline homogeneity, randomisation method, allo-
cation concealment, masking, calibration, follow up, protocol
violation, method of statistics, unit of analysis, CONSORT
implementation, International Standard Randomised Con-
trolled Trial Number Register (ISRCTN) and funding disclo-
sure. Methodology unique to RCTs was not assessed in CCTs,
i.e. randomisation and concealment of allocation.
Randomisation was accepted as adequate, in case the
allocation sequence was correctly generated either by
computer, toss of a coin, throwing dice, etc. Quasi
randomisation, e.g. birth dates, hospital numbers were
not accepted. Adequacy of allocation concealment was
accepted if the sequence was concealed, until interven-
tion was assigned (e.g. in sequentially numbered and
sealed opaque envelopes, remote computer or central
telephone). Statistical analysis was judged as adequate
if appropriate statistical method was selected to accom-
modate to the characteristic of the each individual data
(e.g. number of groups and investigated categories, size
of samples, normally distributed or skewed data, para-
metric or non-parametric, paired or unpaired, numerical
or categorical variables). Statistical significance was ac-
cepted in case of confidence interval (CI) >95 % (p<
0.05), while ‘statistically highly significant’ referred to
CI>99.9 % (p<0.001).
Based on the above, we attempted to categorize the
possible risk of bias as low, moderate or high. Low risk
referred to studies with adequate randomisation method,
sequence concealment and masking of examiner. Studies
were classified as moderate, if one of the above key
categories were missing, or high risk of bias, if more
than one were lacking.
Inclusion criteria
1. All prospective longitudinal studies (i.e. RCTs, CCTs
and cohort studies) were included, where one of the
above mentioned types of interventions were carried
out in the test group, whereas unassisted socket healing
served as control.
2. Studies on healthy individuals, without any age limit,
who underwent ARP following tooth extraction, were
included.
3. Studies had to report on minimum of five patients per
group.
4. Studies, performing clinical or three-dimensional (3D)
radiographic evaluation of hard tissue or histological
assessment, were included.
343
Exclusion criteria
1. Case reports, case series, retrospective analyses were
excluded.
2. Studies without a control group comprising unassisted
socket healing were excluded.
3. Studies on medically compromised patients, e.g. uncon-
trolled diabetes mellitus or cancer were excluded.
4. Studies reporting on immediate placement of dental
implant were excluded.
5. Studies describing extraction of third molars were
excluded.
Search strategy
A sensitive search strategy was designed as we anticipated
that relevant studies might be difficult to locate. The search
strategy incorporated both electronic and hand searches. The
following electronic databases were utilised in Apr 2010: (1)
MEDLINE In-Process & Other Non-Indexed Citations
and MEDLINE 1950 to present via Ovid interface; (2)
EMBASE Classic + EMBASE 1947 to present via Ovid
interface; (3) The Cochrane Central Register of Controlled
Trials (CENTRAL); (4) LILACS.
The electronic search strategy used the following combi-
nation of key words and MeSH terms: (“tooth extraction”
OR “tooth removal” OR “socket” OR “alveol$” OR “ridge”
OR “crest” OR “tooth socket” OR “alveolar bone loss” OR
“bone resorption” OR “bone remodeling”) AND (“preserv
$” OR “reconstruct$” OR “augment$” OR “fill$” OR “seal
$” OR “graft$” OR “repair$” OR “alveolar ridge augmen-
tation” OR “bone regeneration” OR “bone substitutes” OR
“transplantation”).
Cochrane search filters for RCTs and CCTs were imple-
mented. In addition, cohort trials were also searched. The
results were limited to humans only.
An extensive hand search was also performed encom-
passing the bibliographies of the included papers and review
articles. Furthermore the following journals were screened
from 2001 to April 2010: Clinical Oral Implants Research,
Clinical Implant Dentistry and Related Research, European
Journal of Oral Implantology, Implant Dentistry, Interna-
tional Journal of Oral and Maxillofacial Implants, Interna-
tional Journal of Periodontics and Restorative Dentistry,
Journal of Clinical Periodontology, Journal of Dental Re-
search, Journal of Oral and Maxillofacial Surgery, Journal
of Periodontology, Oral Surgery, Oral Medicine, Oral Ra-
diology, Oral Pathology and Endodontics, Periodontology
2000. No language restrictions were applied. Translations
were carried out as necessary by two reviewers (AH, LAM).
The extracted data were copied into Reference Manager
10 software (Thomson Reuters, New York, NY, USA). Thus
the further steps of screening were performed on this
344 Clin Oral Invest (2013) 17:341–363

interface. A three-stage selection of the resulted hits was
performed independently and in duplicate by two reviewers
(AH and LAM). In order to reduce errors and bias, a cali-
bration exercise was performed with the first 500 titles,
resulting in 96.4 % agreement. In case of disagreement at
the title selection stage, the trial was included in the abstract
stage. At the abstract and full text selection any disagree-
ments between the above reviewers were resolved by dis-
cussion. If unresolved, a third reviewer (NM) was involved
for arbitration. The reasons for exclusion were recorded
either in the Reference Manager (abstract stage) or in a
specific data extraction form (full text stage). The level of
agreement was determined by Kappa score calculation.
14 publications eligible for the review [17, 19–21, 23–25,
42–48]. The excluded full text papers along with the reasons
for exclusion are listed in Table 1. The most typical reasons
for exclusion were lack of control group with unassisted
socket healing; use of retrospective design; assessment of
dimensional changes of the AR only on periapical two-
dimensional radiographs, or on casts taken from soft tissue
level; and surgical removal of third molars.
The Kappa score for agreement between the reviewers (AH,
LAM) at the abstract and full text selection level, was 0.96 and
0.90, respectively, indicating a high level of agreement.
Study characteristics

Research synthesis In the 14 included articles (eight RCTs and six CCTs) the
efficacy of ARP techniques was evaluated clinically by
Studies were grouped by research design and their chief means of direct measurements of the residual alveolar ridge
characteristics. Outcomes were recorded in evidence tables. dimensions during re-entry procedures, radiographically by
In view of the marked heterogeneity, no meta-analysis was means of computer tomography or histologically from tre-
conducted. Instead, a narrative synthesis was undertaken. phine biopsies taken at re-entry during osteotomies for
implant placement (Tables 3 and 4). No cohort studies were
indentified. Limited data were reported on confounding
Results factors, such as periodontitis, smoking, systemic disease
and medication. The extraction site distribution was fairly
Search sequence heterogeneous. In some studies ARP was performed only in
maxillary anterior sockets [42, 46, 47], whereas such restric-
The electronic search yielded 6,216 relevant hits after re- tion was not employed in other studies. The residual bone
moval of duplicates (Fig. 1). Subsequently, 157 titles were volume around the investigated sockets, e.g. the presence/
selected for the abstract stage. Following investigation of absence and width of the buccal bone plate varied from
the abstracts, 42 articles qualified for full text evaluation. severely compromised [20, 46], to completely intact, buccal
Four extra papers were then added as a result of the hand bone (Table 3) [17, 21, 42].
search. Assessment of these articles resulted in the following
Intervention characteristics
Electronic search
6.216 titles With regard to the techniques or materials used for ARP, the
6,059
Excluded based included studies were grouped into three categories (Table 3);
on the title
Relevant 1. Bone grafts/substitutes
abstracts 2. GBR
Kappa score 115
0.96 Excluded based 3. Biological active materials.
on the abstract
Relevant full-texts In the majority of the included studies, various bone
42 grafts were utilised, such as autologous bone marrow [47],
3 Included
as a result of plasma rich in growth factor (PRGF) with or without autol-
hand search
Full-text analysis ogous bone [43], DFDBA [17], DBBM [46], calcium sul-
45 phate hemihydrates [42, 45] and bioactive glass [17].
Kappa score 32 Alloplastic polyglycolide/polylactide (PGPL) sponge was
0.90 Excluded based
on the full-text also employed [19, 48]. GBR technique was applied using
non-resorbable expanded polytetrafluoroethylene (e-PTFE)
1 Included [24] or resorbable (PGPL) [25] barrier. Resorbable collagen
as a result of
final search membrane was also employed in combination with FDBA
Included publications [23] or corticocancellous porcine bone [21]. Biological ac-
14
tive material, namely bone morphogenic protein (rhBMP-2)
Fig. 1 Flow chart of the screening process was used on a collagen sponge carrier in one study [20].
Clin Oral Invest (2013) 17:341–363 345

Table 1 List of excluded full text papers and reasons for exclusion

First author Journal Reasons for exclusion

(year of publication)

Bianchi (2004) Int J Periodont Rest Dent Retrospective analysis

Single-arm of the included Fiorellini et al. (2005)
Bolouri (2001) Comp Cont Educ Dent Reported on optical density on two-dimensional radiographs
Brawn (2007) Impl Dent Case report
Brkovic (2008) J Can Dent Assoc Case report
Carmagnola (2003) Clin Oral Impl Res Lack of real control group, resembles to a retrospective analysis
(extreme difference in follow-up period between tests and controls.
T1: 4 months; T2: 7 months; C: 1-15 years, mean: 7.8 years)
Cranin (1988) J Biomed Mat Res Case series without control group
De Coster (2009) Clin Impl Dent Relat Res Case series
Retrospective study as stated by the authors in the discussion
Healing period varied between 1.5 months and 1.5 years
Neither histomorphometry nor clinical or radiographic measurements
reported in the results
Graziani (2008) J Cranofac Surg Extraction of fully impacted third molars
Linear measurements on OPG
Gulaldi (1998) Oral Surg Oral Med Extraction of fully impacted third molars
Oral Pat Oral Rad End Linear measurements on OPG and scintigraphy
Primary outcome was to analyze bone metabolism
Heberer (2008) Clin Oral Impl Res Case series without control group
Hoad-Reddick (1994) Eur J Prosth Rest Dent Two-dimensional linear measurements obtained from OPG and cephalometry
Lack of defined landmarks
Surgical procedure was not described
Hoad-Reddick (1999) Eur J Prosth Rest Dent Description of a method for measurements on casts
Neither socket preservation procedure nor the results were described.
Soft tissue punch technique only
Howell (1997) Int J Periodont Rest Dent Case series without control group
Jung (2004) Int J Periodont Rest Dent Case series without control group
Primary outcome was soft tissue healing
Kangvonkit (1986) Int J Oral Maxillofac Surg Based on OPG and lateral cephalogram only
Evaluation method remains unclear
Primary outcome was the biocompatibility of HA cones
Karapataki (2000) J Clin Periodontol Extraction of fully impacted third molars
Primary outcome was to assess the periodontal status of
second molars after extraction of third molars
Kerr (2008) J Periodontol No biomaterials were used to preserve the ridge dimensions,
therefore did not address the focused question
Kwon (1986) J Oral Maxillofac Surg Based on OPG and lateral cephalogram only
Evaluation method remains unclear
Lack of description of the measurement methods
Molly (2008) J Periodontol Control group was covered by an e-PTFE membrane,
thus lack of unassisted control sockets
Munhoz (2006) Dento Maxillofac Radiol Extraction of fully impacted third molars
Two-dimensional evaluation of periapical radiographs
Norton (2002) Int J Oral Maxillofac Impl Case series without control group
Resembles to a retrospective design
(healing period ranged from 3 to 11 months)
Page (1987) J Oral Maxillofac Surg Case report
Pape (1988) Deutsche Zahnarztliche Augmentation of a resorbed ridge
Zeitschrift
346 Clin Oral Invest (2013) 17:341–363

Table 1 (continued)

First author Journal Reasons for exclusion

(year of publication)

Case series without control group

Penteado (2005) Braz J Oral Sci Immunohistochemical analysis
Did not address the focused question
Quinn (1985) J Am Dent Assoc Clinical measurements at soft tissue level only based on tattoo points,
thus failed to address the focused question
Resembles to a retrospective analysis
Schepers (1993) Impl Dent Retrospective case series without control group
Simon (2004) Ind J Dent Res Extraction of fully impacted third molars
Evaluated soft tissue healing and radiographic analysis based
on the two-dimensional periapical radiographs
Simion (1994) Int J Periodont Rest Dent Titanium implants placed simultaneously
No control group
Primary outcome was microbiological analysis
Smukler (1999) Int J Oral Maxillofac Impl Healed edentulous ridge as control instead of empty socket
No compatibility of the follow-up periods of the different groups
Svrtecky (2003) J Prosth Dent Case report
Throndson (2002) Oral Surg Oral Med Extraction of fully impacted third molars
Oral Pat Oral Rad End Measurements based on two-dimensional periapical radiographs
Yilmaz (1998) J Clin Periodontol Measurement at soft tissue level on study casts

None of the included studies used the socket sealing tech-
nique. Primary flap closure was achieved in 9 out of 14
studies, while the sockets left uncovered in the rests. Various
types and amounts of antibiotics and antiseptic rinses were
administered for different duration in studies reporting on
postoperative care. Finally, average healing period ranged
from one to nine months.
Outcome characteristics
Clinical outcomes
Eight out of the 14 included studies investigated the efficacy
of various ARP techniques to preserve the pre-extraction
ridge dimensions using intra-surgical hard tissue measure-
ments taken during re-entry procedure [19, 21, 23–25, 42,
44, 47]. In these studies, ARP was performed in 137 sockets
of 119 patients and compared to 120 sockets that left to heal
without any treatment in a total of 92 patients (Table 3).
Bone ‘graft’ Four studies evaluated changes in AR dimen-
sions following grafting of the socket. Two studies were RCTs
[42, 47] and two were CCTs [19, 44]. Healing time varied
from 3 to 6 months [19, 42, 44, 47].
The horizontal (bucco-lingual) changes of the alveo-
lar ridge were assessed in three studies [42, 44, 47].
The AR reduced in width from baseline to re-entry
between −1.0 mm and −3.5±2.7 mm following ARP
(p<0.05) and between −2.5 mm and −3.2±1.8 mm in
the control groups (p<0.05). In two out of the three studies,
the width reduction was statistically significantly smaller in
the test groups compared to the controls [42, 47].
Four studies investigated the mean change in ridge height
at the mid-buccal aspect [19, 42, 44, 47]. The AR height
changed from baseline to re-entry between +1.3±1.9 mm
and −0.5 ± 1.1 mm following ARP, and between −0.8 ±
1.6 mm and −1.2±0.6 mm in the control groups. The height
reduction between baseline and re-entry was not statistically
significant in one study in both test and control groups [44],
while one study reported an increase in height instead of
loss following ARP with a PGPL sponge (p<0.05) [19]. In
two out of the four studies, the height reduction was statis-
tically significantly smaller in the test groups compared to
the controls [42, 47].
The vertical dimension changes at the mesial and distal
aspects of the socket were measured in two studies [19, 42]
and did not present any statistically significant difference for
both groups.
Three studies captured data on socket fill and reported
statistically significant differences between baseline and re-
entry in both groups [42, 44, 47], but only one reported
statistically significantly higher socket fill, where bioactive
glass was covered by calcium sulphate, compared to the
unassisted healing [44].
GBR Four studies evaluated changes in AR dimensions
following ARP with GBR alone [24, 25], or in combination
with bone graft [21, 23]. Three studies were RCTs [21, 23,
Clin Oral Invest (2013) 17:341–363
25] and one was CCT [24]. Healing time varied between 4
and 9 months.
Horizontal (bucco-lingual) changes of the AR were
assessed in all four studies. AR width reduction from base-
line to re-entry varied between −1.2±0.9 mm and −2.5±
1.2 mm in the GBR-treated sockets and between −2.6±
2.3 mm and −4.6±0.3 mm in the control groups. With the
exception of one study [23], a statistically significantly
smaller reduction of the alveolar ridge width was observed
when e-PTFE [24], PGPL [25], or collagen membranes in
combination with xenograft [21] were used.
All the four studies investigated the mean change in AR
height at the mid-buccal aspect. The AR height changed
from baseline to re-entry between +1.3±2.0 mm and −0.7±
1.4 mm in the ARP groups and between −0.9±1.6 mm
and −3.6±1.5 mm in the control groups. The resorption in
the ARP group was not statistically significant in three out
of four studies [23–25]. All studies reported a statistically
significantly less post-extraction reduction in AR height
when the socket was treated by GBR compared to unassisted
healing.
Vertical dimension changes at mesial and distal aspects
of the socket were measured in two studies [21, 23]. The
observed differences between baseline and re-entry were not
statistically significant in both groups. In one out of the two
studies the height reduction was statistically significantly
smaller in the test group compared to the control [23].
Two studies captured data on the socket fill [24, 25] and
reported statistically significant socket fill in both groups
between baseline and re-entry, as well as between tests and
controls.
No data were found on either initial buccal plate thick-
ness or alteration of bone volume. However, one study
measured the buccal bone thickness loss and reported sta-
tistically significantly less reduction in the ARP group [47].
Radiographic measurements
Two RCTs, reporting on 3D radiographic assessment, met
the inclusion criteria [20, 46]. The healing time varied from
1 to 4 months. In one study, where the post-extraction socket
was grafted with a radiopaque material (DBBM), treatment
resulted in significantly less reduction in radiographic AR
height compared to unassisted socket healing [46]. The test
group in the other study, where the higher concentration
(1.5 mg/ml) of RhBMP-2 was utilised [20], resulted in a
mean increase of the radiographic AR width by 3.27±
2.53 mm at the most coronal part, compared to the 0.57±
2.56 mm increase in the group of unassisted healing. AR
height was reduced by 0.02±1.2 mm in the same test group
and by 1.17±1.23 mm in the control group (Table 3). The
differences between test and control were statistically
significant.
347
Histological results
Eleven studies carried out a histological analysis based on
trephine biopsies retrieved at re-entry [17, 19–21, 23, 42,
43, 45–48]. Seven studies were RCTs [17, 20, 21, 23, 46,
47] and four were CCTs [19, 43, 45, 48]. In these studies,
ARP was performed in 181 sockets of 158 patients and
compared to 149 sockets that left to heal without any
treatment in 131 patients (Table 4). Only two out of
eight studies reported statistically significantly higher tra-
becular bone volume following ARP in comparison to unas-
sisted socket healing [21, 42] and two studies reported
statistically significantly more connective tissue in the post-
extraction socket when no ARP was performed [17, 21]. On
the contrary, one study reported more vital bone in the
unassisted socket healing group compared to the ARP
group [23]. None of the differences of the investigated
histomorphometric parameters reached statistical signifi-
cance in other studies.
Bone ‘grafts’ Eight studies evaluated histologically the
healing of post-extraction sockets following the application
of some type of bone grafts/substitutes [17, 19, 42, 43,
45–48]. Four studies were RCTs [17, 42, 46, 47] and four
were CCTs [19, 43, 45, 48]. New mineralised bone was
observed at various levels in all studies in both ARP and
control groups in a healing period from 2.5 to 8 months.
Connective tissue occupied a portion of the socket in both
groups. When DFDBA, bioactive glass or DBBM were
used, the graft particles were embedded either in new bone
or in connective tissue. In most studies, there was no sig-
nificant difference in the type of healing, or amount of bone
formation between bone grafts and unassisted socket
healing.
GBR in combination with graft GBR in combination with
graft was utilised in two RCTs. ARP with a collagen mem-
brane and deproteinized porcine bone resulted in statistically
significantly higher new bone and lower connective tissue
formation after 7 to 9 months of healing in comparison to
unassisted socket healing [21]. However, residual graft
materials were present in the ARP biopsies. FDBA and
collagen membrane resulted in similar amounts of new bone
formation to untreated sockets, although more vital bone
was observed in the untreated sockets at 4 to 6 months of
healing (p>0.05) [23].
Biological active material RhBMP-2 in a collagen sponge
carrier was completely resorbed at 4 months following ARP
regardless of the concentration of the growth factor [20].
Mineralised tissue was found and trabecular bone formation
was noticed in two third of both the test and control biopsies
in the RCT.
348
Adverse events, complications
Adverse events were reported in six RCTs [17, 20, 21, 25,
42, 47] and four CCTs [19, 24, 44, 48] including oedema,
pain, erythema and membrane exposure/infection. In two
studies, more adverse events, i.e. oedema, erythema [20] or
membrane exposure [24] were observed in the ARP group
compared to the natural socket healing. No comparison
between tests and controls were reported in the other studies
(Table 3).
Feasibility of implant placement
Seven studies [17, 19, 23, 42, 45, 46, 48] reported that
implant placement in the previous sockets were successful,
but no differences between the ARP and untreated sites were
revealed. The outcome of implant placement remained un-
clear in one article [43] and only re-entry without implanta-
tion was performed in three trials [24, 44]. Four studies
reported the need of further augmentation at the stage of
implant placement. Three of them favoured the ARP group
over the controls, since less [20] or no sites [21, 47] in the
ARP group presented with residual dehiscence or fenestra-
tion defects around the inserted implants (Table 3).
Patient-reported outcome and health economics
No data were found for patient-reported outcome measures
or health economic evaluation.
Quality assessment
Considerable heterogeneity was found among the studies in
terms of methodological quality. Detailed description of the
quality assessment of the included studies is presented in
Table 2. Among the 14 included controlled studies, eight
were randomised [17, 20, 21, 23, 25, 42, 46, 47] although in
four of them the randomisation technique was not reported
[20, 42, 46, 47]. None of the RCTs reported the method of
allocation concealment. Masking of the examiner was
reported at the clinical level in two out of eight [23, 25], at
radiological level in one out of two [20] and at histological
level in four out of 11 studies [17, 21, 42, 43]. Examiner
calibration was declared in three papers [20, 23, 42], whilst
inclusion and exclusion criteria were defined in seven pub-
lications [17, 21, 23, 42, 43, 46, 47]. Apart from three
studies [21, 43, 46] all the other reported the approval of
the ethical committee. Three studies were funded by indus-
try [17, 20, 44], two studies by academic institution [45, 48]
and the remaining nine did not report the source of funding.
Nine trials implemented patient-based analysis [20, 21,
23–25, 42, 44, 47, 48], whilst the extraction site served as
unit of analysis in the rest of the five investigations [17, 19,
Clin Oral Invest (2013) 17:341–363
43, 45, 46]. Sample size calculations were reported only in
three studies [20, 23, 42], although with insufficient data to
evaluate the validity of the calculations. Statistical analysis
was appropriately carried out and described in one study
only [47]. Appropriate statistics were either not carried out
[17, 19–21, 43, 45, 46], or the reported data were insuffi-
cient to determine the validity [23–25, 42, 43, 48]. In addi-
tion, no RCTs were either registered with ISRCTN or
reported using the CONSORT guidelines (Table 3).
Risk of bias
Four studies were classified as moderate risk of bias [17, 21,
23, 25] and the rest were categorised as high risk of bias
(Table 2).
Discussion
Key findings
This systematic review has demonstrated that different ARP
techniques do not totally eliminate post-extraction alveolar
ridge resorption or predictably promote new bone forma-
tion. However, the reduction in ridge width and height
following ARP may be less than that which occurs follow-
ing natural socket healing. The clinical data suggest that the
horizontal ridge contraction was most successfully limited
in the two studies applying GBR without additional bone
grafts [24, 25], whereas the vertical shrinkage was most
efficiently limited by employing GBR with additional bone
graft [21, 23].
Strengths of the review
The present systematic review was limited to randomised
controlled trials, controlled clinical trials and prospective
cohort studies with a control group of empty untreated
sockets. Furthermore, the inclusion criteria of our systematic
review were based on the fact that the clinical merit of
applying the different ARP techniques could only be vali-
dated, if the clinical and histological outcomes following the
application of a technique are superior to that of unassisted
socket healing.
In comparison to the previous systematic reviews [28,
32] the present review has evaluated the histological char-
acteristics of the alveolar socket healing with or without
ARP. The amount and the quality of the newly formed
osseous tissues in the socket area are essential, especially
when the justification of ARP is to facilitate the placement
of a dental implant in the position of a previously extracted
tooth. It is doubtful, whether an ARP technique should be
claimed successful, if it only preserves the external contour
Table 2 Quality assessment of the included studies
Study Quality Criteria Estimated
First author risk of bias
Year of publication Randomisation Masking Calibration Eligibility Criteria Follow up Ethical considerations Funding Statistical analysis Miscellaneous
Type 1. Randomised 1. Therapist 1. Intra-examiner 1. Inclusion 1. Percentage 1. Ethics approval Source of 1. Appropriate 1. Comparable
Reference number 2. Adequate 2. Patient 2. Inter-examiner criteria defined of completed 2. Informed Funding sample size experimental groups
sequence generation 3. Examiner 2. Exclusion follow ups consent calculation and power 2. CONSORT
3. Allocation 4. Statistician criteria defined 2. Adequate 2. Unit of analysis implemented
concealment correction 3. Appropriate 3. ISRCTN registered
4. Concealment statistics applied 4. Other comments
adequate

Aimetti 1. Yes 1. N/R 1. Yes (histo), 1. Yes 1. N/R 1. Yes N/R 1. Insufficient data 1. Yes High
Clin Oral Invest (2013) 17:341–363

2009 2. N/R 2. N/R N/R (clin) 2. Yes 2. N/A 2. Yes to determine 2. N/R
RCT 3. N/R 3. Yes (histo), 2. N/A 2. Patient 3. N/R
.#42 4. N/A N/R (clin) 3. Insufficient data
4. N/R to determine
*Reported as
‘double blind’

Anitua 1. Yes (btw T-C) 1. N/R 1. N/R 1. Yes 1. 100% 1. N/R N/R 1. N/R 1. N/R High
1999 No (within T) 2. N/R 2. N/A 2. Yes 2. Yes 2. Yes 2. Patient + site 2. N/R
CCT 2. N/A 3. Yes 3. No statistical analysis 3. N/R
#43 3. N/R 4. N/R was carried out 4. At severe defects
4. N/A autogenous bone
was added to PRGF.
Different healing periods.

Barone 1. Yes 1. N/R 1. N/R 1. Yes 1. 100% 1. N/R N/R, declared 1. N/R 1. Yes Moderate
2008 2. Yes 2. N/R 2. N/A 2. Yes 2. Yes 2. Yes no conflict 2. Patient 2. N/R
RCT 3. N/R 3. Yes (histo), of interest 3. No 3. N/R
#21 4. N/A N/R (clin) 4. Different healing
4. N/R periods.

Camargo N/A 1. N/R 1. N/R 1. Yes 1. 100% 1. Yes Industry 1. N/R 1. N/R High
2000 2. N/R 2. N/A 2. Yes 2. Yes 2. Yes 2. Patient 2. N/R
CCT 3. N/R 3. Insufficient data 3. N/R
#44 4. N/R to determine

Fiorellini 1. Yes 1. N/R 1. N/R 1. No 1. 100% 1. Yes Industry 1. Insufficient data 1. N/R High
2005 2. N/R 2. N/R 2. Yes 2. No 2. Unclear 2. Yes to determine 2. N/R
RCT 3. N/R 3. Yes (CT scans) 2. Patient 3. N/R
#20 4. N/A 4. N/R 3. No 4. Standardisation of
* Reported CT scans N/R.
as ‘double Final number
blind’ of sockets, patients
remain unclear.

Froum 1. Yes 1. N/R 1. N/R 1. Yes 1. 100% 1. Yes Industry 1. N/R 1. N/R Moderate
2002 2. Yes 2. N/R 2. N/A 2. Yes 2. Unclear 2. Yes 2. Site 2. N/R
RCT 3. N/R 3. Yes 3. No 3. N/R
#17 4. N/A 4. N/R 4. Different healing periods.
Enrolment of sites of
subjects inconsistent.
349
Table 2 (continued)
350

Study Quality Criteria Estimated

First author risk of bias
Year of publication Randomisation Masking Calibration Eligibility Criteria Follow up Ethical considerations Funding Statistical analysis Miscellaneous
Type 1. Randomised 1. Therapist 1. Intra-examiner 1. Inclusion 1. Percentage 1. Ethics approval Source of 1. Appropriate 1. Comparable
Reference number 2. Adequate 2. Patient 2. Inter-examiner criteria defined of completed 2. Informed Funding sample size experimental groups
sequence generation 3. Examiner 2. Exclusion follow ups consent calculation and power 2. CONSORT
3. Allocation 4. Statistician criteria defined 2. Adequate 2. Unit of analysis implemented
concealment correction 3. Appropriate 3. ISRCTN registered
4. Concealment statistics applied 4. Other comments
adequate

Guarnieri N/A 1. N/R 1. N/R 1. Yes 1. N/R 1. Yes Government; 1. N/R 1. N/R High
2004 2. N/R 2. N/A 2. No 2. N/A 2. Yes institution 2. Site 2. N/R
CCT 3. N/R 3. No 3. N/R
#45 4. N/R

Iasella 1. Yes 1. N/R 1. Yes 1. Yes 1. 100% 1. Yes N/R 1. Insufficient data 1. Yes Moderate
2003 2. Yes 2. N/R 2. N/A 2. Yes 2. Yes 2. Yes to determine 2. N/R
RCT 3. N/R 3. Yes 2. Patient 3. N/R
#23 4. N/A 4. N/R 3. Insufficient data
to determine

Lekovic N/A 1. N/R 1. N/R 1. No 1. 70% (premature 1. Yes N/R 1. N/R 1. Yes High
1997 2. N/R 2. N/A 2. No exposure of e-PTFE 2. N/R 2. Patient 2. N/R
CCT 3. N/R barrier in 3/10) 3. Insufficient data
#24 4. N/R 2. Yes to determine 3. N/R

Lekovic 1. Yes 1. N/R 1. N/R 1. No 1. 100% 1. Yes N/R 1. N/R 1. Yes Moderate
1998 2. Yes 2. N/R 2. N/A 2. No 2. Yes 2. Yes 2. Patient 2. N/R
RCT 3. N/R 3. Yes 3. Insufficient data 3. N/R
#25 4. N/A 4. Yes to determine

Nevins 1. Yes 1. N/R 1. N/R 1. Yes 1. 100% 1. N/R N/R 1. N/R 1. Yes High
2006 2. N/R 2. N/R 2. N/A 2. Yes 2. Yes 2. N/R 2. Site 2. N/R
RCT 3. N/R 3. N/R 3. No 3. N/R
#46 4. N/A 4. N/R 4. Standardisation of CT
scans N/R. Test material
radiopaque. Different
healing periods.

Pelegrine 1. Yes 1. N/R 1. N/R 1. Yes 1. 100% 1. Yes N/R 1. N/R 1. N/R High
2010 2. N/R 2. N/R 2. N/A 2. Yes 2. Yes 2. Yes 2. Patient 2. N/R
RCT 3. N/R 3. N/R 3. Yes 3. N/R
#47 4. N/A 4. N/R

Serino N/A 1. N/R 1. N/R 1. Yes 1. 80% 1. Yes N/R 1. N/R 1. N/R High
2003 2. N/R 2. N/A 2. No 2. Unclear 2. Yes 2. Site 2. N/R
CCT 3. N/R 3. No 3. N/R
#19 4. N/R 4. Molars only in T.
Clin Oral Invest (2013) 17:341–363
Clin Oral Invest (2013) 17:341–363 351

risk of bias

N/A not applicable; N/R not reported, T test; C control; RCT randomised controlled trial; CCT controlled clinical trial; PRGF platelet-rich growth factor; CONSORT Consolidated Standards of
Estimated
of the AR, but the newly formed tissue is of inferior quality

High
and quantity (percentage of matured trabecular bone) to
what is normally achieved following a tooth extraction.
Finally, the quality of the included studies has also been
meticulously assessed in this review. Such a quality evalu-
3. ISRCTN registered
experimental groups

4. Other comments
ation of the retrieved data is essential to estimate the source
1. Comparable
Miscellaneous

2. CONSORT
implemented

and magnitude of potential bias that may lead to delusive

conclusions.
1. N/R
2. N/R
3. N/R
Strength of evidence—risk of bias
calculation and power

3. Insufficient data
2. Unit of analysis
Statistical analysis

The quality assessment of the included studies in this sys-

statistics applied

to determine
1. Appropriate

3. Appropriate

tematic review revealed that none of the trials have qualified

sample size

2. Patient

for a low risk of bias category. Ten out of the 14 studies

1. N/R

presented with high risk of bias thus their results must be

evaluated with caution. The lack of clear reporting of re-
Government;
institution

search methodology elements, such as adequate randomiza-

Source of
Funding

Funding

tion and concealment and/or masking of the therapist and

the examiner were among the primary reasons for the high
risk of bias [49]. We did not contact authors for clarification
Ethical considerations
1. Ethics approval

of unclear methodology. Therefore, it is possible that actual

study conduct was better than that reported in the publica-
2. Informed

tion. Statistical considerations played important role as well,

consent

1. Yes
2. Yes

since appropriate analytical statistics was completed and

reported merely in one study [47]. Power calculation was
conducted in three trials only [21, 23, 42], nevertheless the
reported data were insufficient to determine the validity of
Reporting Trials; ISRCTN International Standard Randomised Controlled Trial Number Register
1. Percentage
of completed

2. Adequate
follow ups

2. Unclear
Follow up

the calculation.
correction

1. 80%

Dimensional changes and histological characteristics

Eligibility Criteria

criteria defined

criteria defined

Sufficient ridge width and height have been considered as

2. Exclusion
1. Inclusion

one of the key requirements for successful implant therapy

1. Yes
2. No

and for the establishment of an aesthetically pleasing emer-

gence profile at fixed partial dentures [8, 50, 51]. Therefore,
1. Intra-examiner
2. Inter-examiner

the alterations in oro-facial (horizontal) and apico-coronal

Calibration

(vertical) AR dimensions were selected as the primary out-

2. N/A
1. N/R

comes of the present review. Direct intra-surgical measure-

ments on the AR at re-entry are considered as the most
precise method to evaluate the bone volume changes fol-
4. Statistician

lowing ARP. It is desirable though to establish and validate a

3. Examiner
1. Therapist
2. Patient
Masking

surrogate measure that avoids the need for re-entry surgery,

1. N/R
2. N/R
3. N/R
4. N/R

while providing the clinician with a reliable measure. Two-

dimensional radiographs, such as periapical or panoramic
sequence generation

radiographs, are not ideal to estimate the 3D changes of the

4. Concealment
Quality Criteria

1. Randomised
Randomisation

AR [52]. Also, measurements of the alveolar mucosa level

3. Allocation
concealment
2. Adequate

adequate

or study casts incorporate not only the alveolar bone, but

N/A
Table 2 (continued)

also the overlaying soft tissue. For these reasons only

studies performing clinical or 3D radiographic evaluation
Year of publication

Reference number

of hard tissue were included in this review. Cone-beam

computerised tomography (CBCT) appears to offer a valid
First author

technique to assess alveolar ridge changes, with newer mod-

Serino
Study

2008
Type

CCT
#48

els greatly reducing radiation exposure [53]. However, a

 352

Table 3
First author Trial Population Confounding Defect Test material Control Surgical Follow-up Alveolar ridge Alveolar ridge Implant
Year of characteristics characteristics factors characteristics (number of (number of management 1. Healing dimension dimension 1. Feasibility
publication 1. Country 1. Age range 1. Smoking 1. Socket sockets/ sockets/ 1. Type of flap period changes in changes in of implant
Type 2. Number of (mean) in 2. Periodontitis location subjects) subjects) 2. Soft tissue 2. Number horizontal width vertical height placement
Design centres years 2. Defect closure of drop-outs Mean/median mm Mean/median mm 2. Necessity of
Methodology 3. Setting 2. Number of morphology 3. Postoperative 3. Adverse 1. Whole ridge (reference point) simultaneous
Reference patients antimicrobials events 2. Buccal plate 1. Mid-buccal augmentation
number (sockets) 2. Mesial
3. Distal
4. Socket Fill

Aimetti 1. Italy 1. 36-68 1. No 1. Maxillary Calcium Empty 1. Flapless 1. 3 months 1. T: -2.0±1.1** 1. T: -0.5±1.1*, 1. Implants
2009 2. 1 (51.27 ±8.4) 2. N/R anterior sulphate (18/18) 2. No primary 2. N/R C: -3.2±1.8**, C: -1.2±0.6**, *** were
RCT 3. University 2. 40 (40) 2. 4-wall Hemihydrate closure 3. Uneventful *** 2. T: -0.2±0.6, inserted
Parallel configuration (22/22) 3. Amoxicillin healing 2. N/R C: -0.5±0.9 2. N/R
Clin+Histo 2g/day for 3. T: -0.4±0.9,
5 days, C: -0.5±1.1
#42 Chlorexidine 4. T: 11.3±2.8**,
0.12% for C: 10.0±2.3**
2 weeks (Acrylic stent)

Anitua 1999 1. Spain 1. T: 35-55 1. Yes 1. Any T1: PRGF Empty 1. Full-thickness 1. 2.5 – 4 N/A N/A 1. N/R
CCT 2. 1 (41) (5+3/5+3) (10+3/ months
Parallel+Split- 3. Private 2. Yes 2. Variable 2. Primary 2. N/R
C: 38-54 (42) T2: PRGF+ 10+3) closure 2. 0
mouth practice 2. 23 (26) Autologous 3. Amoxicillin 3. N/R
Histo
bone (5/5) 1.5g/day for
#43 5 days

Barone 1. Italy 1. 26-69 1. <10/day 1. Non-molars Corticocancellous Empty 1. Full-thickness 1. 7-9 months 1. T: -2.5±1.2*, 1. T: -0.7±1.4*, 1. ‘Implants were
2008 2. 1 2. 40 (40) 2. Yes 2. 4-wall porcine bone+ (20/20) 2. Primary closure 2. 0 C: -4.5±0.8*, *** C: -3.6±1.5*, *** inserted in
RCT 3. Hospital (treated) configuration collagen 3. Amoxicillin 3. Uneventful 2. N/R 2. T: -0.2±0.8, both groups’
Parallel membrane 2g/day for healing C: -0.4±1.2 2. Some GBR
Clin+Histo (20/20) 4 days+ (pain, swelling) 3. T: -0.4±0.8, were needed
#21 Chlorexidine C: -0.5±1.0 due to buccal
0.12% for dehiscence in
3 weeks 4. N/R
the control
(Acrylic stent) group

Camargo 1. USA, 1. 28-60 1. N/R 1. Maxillary Bioactive glass+ Empty 1. Full-thickness 1. 6 months 1. T: -3.48±2.68**, 1. T: -0.38±3.18, 1. Reentry only
2000 Yugoslavia (44±15.9) 2. N/R anterior, covered by (16/8) with 4 vertical 2. N/R C: -3.06±2.41** C: -1.00±2.25 2. N/A
CCT 3. University 2. 16 (32) premolars calcium releasing 3. Uneventful 2. N/R (titanium tack)
Split-mouth 2. N/R 2. N/R sulphate incisions healing 2. N/R
Clin layer (16/8) 2. No primary 3. N/R
#44 closure 4. T: 6.43±2.78**,
3. Penicillin C: 4.00±2.33**, ***
1.5g/day for (to buccal
7 days+ bone crest)
Chlorexidine
0.12% for
2 weeks
Clin Oral Invest (2013) 17:341–363
Table 3 (continued)
First author Trial Population Confounding Defect Test material Control Surgical Follow-up Alveolar ridge Alveolar ridge Implant
Year of characteristics characteristics factors characteristics (number of (number of management 1. Healing dimension dimension 1. Feasibility
publication 1. Country 1. Age range 1. Smoking 1. Socket sockets/ sockets/ 1. Type of flap period changes in changes in of implant
Type 2. Number of (mean) in 2. Periodontitis location subjects) subjects) 2. Soft tissue 2. Number horizontal width vertical height placement
Design centres years 2. Defect closure of drop-outs Mean/median mm Mean/median mm 2. Necessity of
Methodology 3. Setting 2. Number of morphology 3. Postoperative 3. Adverse 1. Whole ridge (reference point) simultaneous
Reference patients antimicrobials events 2. Buccal plate 1. Mid-buccal augmentation
number (sockets) 2. Mesial
3. Distal
4. Socket Fill

Fiorellini 1. USA 1. 47.4 1. N/R 1. Maxillary T1: 1.5mg/ml Empty 1. Full-thickness 1. 4 months 1. Coronal: 1. T1: -0.02±1.2, 1. N/R
Clin Oral Invest (2013) 17:341–363

2005 2. 8 centres 2. 80 (95) 2. N/R anterior, rhBMP-2 (?/20?) with vertical T1: +3.27±2.53*, T2: -0.62±1.39*,
2. No drop-outs 2. No need for
RCT 3. University premolars (?/21?) incisions reported. T2: +1.76±1.67*, T3: -1.00±1.40*, augmentation
Parallel 2. ≥50% T2: 0.75mg/ml 2. Primary (3 patients T3: +0.82±1.40, C: -1.17±1.23*,
C: +0.57±2.56, *** *** (T1 vs C) T1: 18/21 (86%)
Radiogr+ buccal bone rhBMP-2 closure incorrectly
Histo loss (?/22?) randomized, (T1 vs T2/T3/C) 2. N/R T2: 12/22 (55%)
3. Penicillin (?mg)
#20 T3: Collagen for 7-10 days+ 1 patient 2. N/R 3. N/R T3: 10/17 (59%)
sponge (?/17?) Chlorexidine received 4. N/R C: 9/20 (45%)
0.12% different
graft) (T1 vs T2/C)***
3. 250 (T>C)

Froum 1. USA 1. 35-77 1. No 1. Any T1: Bioactive Empty 1. Full-thickness 1. 6-8 months N/A N/A 1. ‘An implant
2002 2. Single (54.9±11.9) 2. N/R 2. 4-wall glass (10/8) (10/10) without vertical 2. 0 of appropriate
RCT centre 2. 19 (30) configuration, T2: DFDBA incisions 3. Uneventful size was placed
≤2mm buccal (10/8) 2. Primary healing in the healed
Split mouth 3. University
plate loss closure sockets.’
Histo 3. Doxycycline
100mg/day 2. N/R
#17
for 13 days+
Chlorexidine
0.12% for
30 days

Guarnieri 1. Italy 1. 35-58 1. N/R 1. Maxillary, Calcium Empty 1. Full-thickness 1. 3 months N/A N/A 1. ‘Bucco-lingual
2004 2. N/R 2. 10 (25) 2. Yes mandibular sulphate (5/5) without vertical 2. N/R dimensions of
CCT 3. N/R anteriors, Hemihydrate incisions 3. N/R the alveolar
Parallel+ premolars (10/10) 2. Primary closure ridge enabled
Split 2. socket with 3. Amoxicillin safe insertion of
mouth ridge (?mg) for titanium
Histo resorption 1 week+Chlorexidine implant.’
#45 ≥50% were 0.2% for 2 weeks 2. N/R
excluded

Iasella 2003 1. USA 1. 28-76 1. Yes 1. Maxillary Tetracycline Empty 1. Full-thickness 1. 4 or 6 months 1. T: -1.2±0.9*, 1. T: +1.3±2.0, 1. Implants
RCT 2. N/R (51.5±13.6) 2. N/R anteriors, hydrated (12/12) without vertical (combined) C: -2.6±2.3* C: -0.9±1.6*** successfully
Parallel 3. N/R 2. 24 (24) premolars FDBA + incisions 2. 0 2. N/R 2. T: -0.1±0.7, placed at all
Clin+Histo and collagen 2. No primary closure 3. N/R C:-1.0±0.8*** sites
#23 mandibular membrane 3. Doxycyclin 3. T: -0.1±0.7, 2. Some sites had
premolars (12/12) 200mg/day for C: -0.8±0.8*** slight dehiscence
2. N/R 1 week+ 4. N/R and required
Chlorexidine (Acrylic stent) further
0.12% for augmentation
2 weeks
353
Table 3 (continued)
354

First author Trial Population Confounding Defect Test material Control Surgical Follow-up Alveolar ridge Alveolar ridge Implant
Year of characteristics characteristics factors characteristics (number of (number of management 1. Healing dimension dimension 1. Feasibility
publication 1. Country 1. Age range 1. Smoking 1. Socket sockets/ sockets/ 1. Type of flap period changes in changes in of implant
Type 2. Number of (mean) in 2. Periodontitis location subjects) subjects) 2. Soft tissue 2. Number horizontal width vertical height placement
Design centres years 2. Defect closure of drop-outs Mean/median mm Mean/median mm 2. Necessity of
Methodology 3. Setting 2. Number of morphology 3. Postoperative 3. Adverse 1. Whole ridge (reference point) simultaneous
Reference patients antimicrobials events 2. Buccal plate 1. Mid-buccal augmentation
number (sockets) 2. Mesial
3. Distal
4. Socket Fill

Lekovic 1. Yugoslavia 1. (49.8) 1. N/R 1. Maxillary e-PTFE Empty 1. Full-thickness 1. 6 months 1. 10/10:, 1. 10/10: 1. Reentry only
1997 / USA 2. 10 (20) 2. N/R and membrane (10/10) with 4 vertical 2. 3/10 drop-outs T: -1.80±0.51, T: -0.5±0.22, 2. N/A
CCT 2. N/R mandibular (10/10) releasing due to premature C: -4.40±0.61**, C: -1.2±0.13**,
Split-mouth (presumably anteriors, incisions membrane *** ***
Clin single centre) premolars 2. Primary closure exposure 7/10: T: -1.71±0.75, 7/10:
#24 3. University 2. N/R 3. Penicillin 3. 3/10 exposed, C: -4.43±0.72**, T: -0.28±0.18,
1g/day for 7/10 no *** C: -1.0±0.0**,
7 days+ infection 3/10: T: -2.00±0.00, ***
Chlorexidine C: -4.33±0.88* 3/10: T: -1.0±0.58,
0.2% 2. N/R C: -1.66±0.33
(titanium tack)
2. N/R
3. N/R
4. 10/10:
T: 4.9±0.86*,
C: 3.0±0.63,
***
7/10: T: 5.43±1.1*,
C:2.92±1.61, ***
3/10: T: 3.66±1.20,
C: 4.33±1.45
(to buccal bone crest)

Lekovic 1. Yugoslavia 1. (52.6±11.8) 1. N/R 1. Maxillary PG/PL Empty 1. Full-thickness 1. 6 months 1. T: -1.31±0.24* 1. T: -0.38±0.22, 1. Reentry only
1998 2. 1 2. 16 (32) 2. Yes (treated) and membrane (16/16) with 4 vertical 2. 0 C:-4.56±0.33*, C: -1.50±0.26*, 2. N/A
RCT 3. University mandibular (16/16) releasing incisions 3. Uneventful *** *** (titanium tack)
Split-mouth anteriors, 2. Primary closure healing 2. N/R 2. N/R
Clin premolars 3. Penicillin 1g/day 3. N/R
#25 2. N/R for 7 days+
4. T: 5.81±0.29*,
Chlorexidine 0.12%
C: 3.94±0.35*, ***
for 2 weeks
(to buccal bone crest)

Nevins 2006 1. USA / Italy 1. N/R 1. N/R 1. Maxillary anterior DBBM (19/9) Empty (17/9) 1. Partial 1. 1 – 3 months N/A 1. T: -2.42±2.58, 1. Implants were
RCT 2. N/R 2. 9 (36) 2. Yes 2. Buccal plate was thickness (biopsies at 6M) C: -5.24±3.72*** placed, but
Split-mouth 3. N/R compromised 2. Primary 2. 0 2. N/R number
Radiogr+ closure 3. N/R 3. N/R unknown
Histo 3. N/R 4. N/R (At 6 mm 2. N/R
#46 ridge width)
Clin Oral Invest (2013) 17:341–363
Table 3 (continued)
First author Trial Population Confounding Defect Test material Control Surgical Follow-up Alveolar ridge Alveolar ridge Implant
Year of characteristics characteristics factors characteristics (number of (number of management 1. Healing dimension dimension 1. Feasibility
publication 1. Country 1. Age range 1. Smoking 1. Socket sockets/ sockets/ 1. Type of flap period changes in changes in of implant
Type 2. Number of (mean) in 2. Periodontitis location subjects) subjects) 2. Soft tissue 2. Number horizontal width vertical height placement
Design centres years 2. Defect closure of drop-outs Mean/median mm Mean/median mm 2. Necessity of
Methodology 3. Setting 2. Number of morphology 3. Postoperative 3. Adverse 1. Whole ridge (reference point) simultaneous
Reference patients antimicrobials events 2. Buccal plate 1. Mid-buccal augmentation
number (sockets) 2. Mesial
3. Distal
4. Socket Fill

Pelegrine 1. Brazil 1. 28-70 1. No 1. Maxillary Autologous Empty 1. Full-thickness 1. 6 months 1. T: -1.0*, 1. T: -0.5*, 1. All implants
Clin Oral Invest (2013) 17:341–363

2010 2. 1 (47.5±10.3) 2. N/R anteriors bone marrow (15/6) with 2 buccal 2. 0 C: -2.5*, *** C: -1.0*, *** osseointegrated
RCT 3. University 2. 13 (30) 2. Sockets with (15/7) vertical releasing 3. Uneventful 2. T: -0.75, (Titanium screw) 2. T: without
Parallel severe bone incisions healing C: -1.75, *** 2. N/R further
Clin+histo loss were 2. Primary closure 3. N/R augmentation,
#47 excluded 3. N/R 4. T: 10.33*, C: 10.32* C: At 5 sites
(to buccal bone crest) augmentation
or expansion
carried out

Serino 2003 1. Italy 1. 35-64 1. N/R 1. Any PG/PL sponge Empty 1. Full-thickness 1. 6 months N/A 1. T: +1.3±1.9*, 1. Placement of
CCT 2. 1 2. 45 (39) 2. Yes 2. Buccal plate (26/24) after (13/12) buccally and 2. 9 drop-outs C: -0.8±1.6 implants in all
Parallel+ 3. N/R before (treated) could be drop-out after drop-out lingually for reasons 2. T: -0.2±1.0, C and T sites
split-mouth drop-out partially or 2. No primary unrelated to C: -0.6±1.0 with good
Clin+Histo completely closure the therapy 3. T: -0.1±1.1, primary stability
#19 lost 3. No 3. Uneventful C: -0.8±1.5 2. N/R
antibiotics; healing 4. N/R
Chlorexidine (Acrylic stent)
0.2% for
2 weeks

Serino 2008 1. Italy 1. 32-64 1. N/R 1. Any PG/PL sponge Empty (9/9) 1. Full-thickness 1. 3 months N/A N/A 1. Placement of
CCT 2. 1 2. 20 (20) 2. Yes non-molars (7/7) after drop-out buccally and 2. 4 drop-outs implants in all
Parallel 3. N/R before (treated) 2. Alveolar after drop-out lingually for reasons C and T sites
Histo drop-out bone height 2. No primary unrelated to with good
#48 ≥8mm closure the therapy primary stability
3. No Antibiotics; 3. Uneventful 2. N/R
Chlorexidine healing
0.2% for 2 weeks

* p<0.05; statistically significant intra-group difference, baseline to final; ** p<0.001 statistically highly significant intra-group difference, baseline to final; *** p<0.05 statistically significant
inter-group difference, between test and control;
N/A not applicable; N/R not reported; T test; C control; M=month(s); Clin clinical analysis; Histo histological analysis; Radiogr radiographic analysis; RCT randomised controlled trial; CCT
controlled clinical trial; PRGF plasma rich in growth factors; DFDBA demineralised freeze-dried bone allograft; FDBA freeze-dried bone allograft; e-PTFE expanded-polytetrafluorethylen; PG/PL
polyglycolide/polylactide; DBBM demineralised bovine-bone mineral
355
 356

Table 4

First author Number of Histomorphology Histomorphometry Statistical difference

biopsies between test and
Year of publication (test material) Test Control (mean or median %) control
Type
Healing period
Reference number
RCT
Aimetti 2009 T: N/R 22? No residual graft material. No inflammatory 100% living bone (mostly woven) Trabecular bone: Residual Woven bone: Lamellar T vs C*
3M (MGCSH) infiltrate. New bone formation in all in all biopsies. Lamellar bone T: 58.8±3.5 substitute Coronal: bone:
#42 C: N/R 18? specimens, 100% living trabecular bone remodeling was starting. C: 47.2±7.7 material: T: 83.6±6.6 Coronal:
with woven and lamellar structure. T: 0.0 C: 88.9±7.6 T: 16.4±6.6
C: N/A Middle: C: 11.1±7.6
T: 59.6±13.2 Middle:
C: 81.1±7.6 T: 40.4±13.2
Apical: C: 18.9±7.6
T: 56.4±10.9 Apical:
C: 77.8±8.1 T: 43.6±10.9
C: 22.2±8.1

Anitua T: N/R (PRGF± Compact mature bone with well-organized Connective tissue fills the main N/R
1999 autogen bone) trabeculae and morphology in 8/10 patients. part of the defect. No mature
CCT C: N/R Connective tissue with non-organized bone.
2.5 – 4 M trabeculae in 2/10 patients. Significant
#43 intra-group differences 10 vs. 16 weeks!

Barone 2008 T: 20 Residual graft material embedded in newly Typically trabecular bone pattern. Total bone Connective Residual graft Bone: T>C*
RCT (Corticocancellous formed bone in all specimens. Complete Large marrow spaces filled with volume: tissue: material: Connective tissue:
7–9M porcine bone+ bone fill. adipocytes. Lamellar bone was T: 35.5±10.4 T: 36.6±12.6 T: 29.2±10.1 T<C*
#21 collagen also present within the bone C: 25.7±9.5 C: 59.1±10.4 C: N/A
membrane) marrow.
C: 20

Fiorellini 2005 T1: 16 (rhBMP-2 No evidence of inflammation or residual graft. Trabecular bone formation in 2/3 N/R
RCT 1.5mg/ml) of the samples. Mineralized tissue formation presented with different level of
4M T2: 15 remodeling. Minor osteoclastic activity. No comparison reported between
#20 (0,75mg/ml) T and C!
T3: 11
(Collagen sponge)
C: 14

Froum 2002 T1: 10 T1: New bone formation. Osteoid surrounded N/R Vital bone: Connective Residual bone Connective tissue:
RCT (Bioactive glass) and penetrated the bioactive glass particles. T1: 59.5 tissue: substitute: T1<T2 or C*
6–8M T2: 10 (DFDBA) T2: Varying degrees of reossification T2: 34.7 T1: 35.3 T1: 5.5
#17 C: 10 around DFDBA. C: 32.4 T2: 51.6 T2: 13.5
C: 67.0 C: N/A
Clin Oral Invest (2013) 17:341–363
Table 4 (continued)
First author Number of Histomorphology Histomorphometry Statistical difference
biopsies between test and
Year of publication (test material) Test Control (mean or median %) control
Type
Healing period
Reference number

Guarnieri 2004 T: 10 (MGCSH) Almost complete absence of MGCSH. Less bone formation compared Trabecular bone No statistical significance
CCT C: 5 Absence of connective tissue and to test sites. area: could be drawn due
3M inflammatory cells. In all sections T: Coronal: 58.6±9.2 to small number of
#45 trabecular bone formation with no Middle: 58.1±6.2 control specimens.
Clin Oral Invest (2013) 17:341–363

differences between the apical, middle Apical: 58.3±7.8

and coronal levels. C: ≤ 46

Iasella 2003 T: 4M: 5, 6M:7 Residual graft particles surrounded by Similar amount of total bone and Vital bone: Non-vital bone: N/R
RCT (Tetracycline woven bone or by connective tissue. trabecular spaces as in test. 4M 4M
4–6M hydrated (No biopsy from 2 C sites due T: 31±9 T: 32±19
#23 FDBA+ to minimal bone fill) C: 58±11 C: N/A
Collagen 6M 6M
membrane) T: 25±17 T: 41±18
C: 4M: 5, 6M: 5 C: 50±14 C: N/A
Combined Combined
T: 28±14 T: 37±18
C: 54±12 C: N/A

Nevins 2005 T: 5 (DBBM) DBBM granules present. Apically integrated New bone formation No comparison made.
RCT C: 5 in cancellous bone but coronally in soft
6M tissue. No signs of inflammation or
#46 foreign body reaction.

Pelegrine 2010 T: 7 (Autologous Mineralized bone: No significant difference.

RCT bone marrow) T: 45.0
6M C: 6 C: 43.75
#47

Serino 2003 T: 10 No residual graft material. Presence of Presence of mineralized bone. Mineralized bone: Statistical comparison
CCT (PG/PL sponge) matured, mineralized bone. Lack of Wide marrow spaces. T: 66.7 cannot be made due
6M C: 3 coronal soft tissue ingrowth. C: 43.7 to the small number
#19 of control specimens.

Serino 2008 T: 7 No residual graft material. Scarce presence of Coronal: trabecular bone with wide Mineralized bone: No significant
CCT (PG/PL sponge) inflammatory tissue. Coronal: newly formed marrow spaces with connective T: 59.9±22.4 difference.
3M C: 9 trabecular bone with large marrow spaces. tissue. Apical: more mature and C: 48.8±14.4
#48 Apical: more mature and compact bone. compact bone.

*p<0.05; statistically significant difference between test and control

T test; C control; M month(s); N/R not reported; N/A not applicable; vs. versus; TBV total bone volume; MGCSH medical grade calcium sulphate hemihydrate; DFDBA demineralised freeze-dried
357

bone allograft; FDBA mineralised freeze-dried bone allograft; DBBM demineralised bovine-bone mineral; PG/PL polyglycolide/polylactide
358
prerequisite of this technique would be some type of stand-
ardisation, so that the captured image is being always taken
from exactly identical positions [54]. None of the two included
radiographic studies reported on such standardisation [20, 46].
For the interpretation of the results we attempted to
cluster the studies in respect to the type of intervention.
Unassisted sockets In the present review, the mean reduc-
tion of the AR width of the untreated sites varied between
2.6±2.3 mm and 4.6±0.3 mm and the mean reduction of the
AR height was between 0.8±1.6 mm and 3.6±1.5 mm after
1 to 9 months of healing. This corroborates the result of a
previous clinical study which indicated that 95 % of AR
reduction should be expected after three months of extrac-
tion [1]. Furthermore, it is in agreement with a recent sys-
tematic review, which reported that the average reduction of
the AR width seemed to be higher (3.87 mm), than the
reduction in AR height (1.67 mm) [55].
Even though both AR width and height present resorp-
tion, histologically, new bone formation up to a variable
extent was also observed in some studies as result of unas-
sisted socket healing [19–21, 23, 42, 45, 46, 48]. In addi-
tion, a large area was occupied by bone marrow [19, 21, 48],
as reported in preclinical studies [11, 13, 56]. Only a single
study reported on connective tissue fill and lack of mature
bone [43].
Bone grafts and substitutes Effective grafting procedures for
bone augmentation have been associated with the osteocon-
ductive, osteoinductive or osteogenetic properties of the graft
[56–59]. This led to the assumption that the placement of these
materials in the extraction socket may accelerate new bone
formation by the above biological properties and may also
reduce AR resorption by stabilising the blood clot, providing a
scaffold and external source of minerals and/or collagen [11,
12, 60, 61]. The placement of DBBM with collagen in fresh
extraction sockets resulted in limited reduction of the AR
dimensions, although delayed initial socket healing in terms
of new bone formation was also observed [11, 12]. Human
studies reported similar unfavourable histological observa-
tions when DFDBA was employed for ARP [15, 16].
In the present review of human experiments, two out of
three studies reported that socket grafting with autologous
bone marrow [47] or alloplastic material [42] have signifi-
cantly limited the reduction of the AR width compared to
the unassisted socket healing. Three out of five studies
reported that reduction of the resorption in AR height was
significant [42, 46, 47], while the ridge height was even
increased in one study, where sockets were grafted with
polymer sponge [19]. We should emphasise though that
since the graft material (DBBM) in a CT study possessed
radiopaque characteristic, the alteration of the AR contour
on the CT image should be interpreted with caution [46].
Clin Oral Invest (2013) 17:341–363
Based on the histological evaluation of these studies, the
above AR dimensional changes were not necessarily accom-
panied by higher amount of new bone formation in the
socket, since the quality of newly formed tissue in the
ARP sites was comparable to that in the control sites.
Furthermore, the sockets were occupied by a mixture of
new bone and connective tissue which in many occasions
was surrounding the graft particles [17, 21, 46] (Table 4).
GBR (membrane alone or in combination with ‘graft’) The
conception of guided bone and tissue regeneration [62] was
translated to ARP procedures in order to exclude epithelial
cells from the extraction socket by the use of barrier mem-
brane in four studies of the present review [21, 23–25].
(a) GBR with membrane alone
ARP with GBR resulted in statistically significantly
less resorption in ridge width and height compared to
unassisted socket healing, regardless of the type of
membrane [24, 25]. It should be noted that in one study
[24], in three out of 10 cases, the exposed non-
resorbable e-PTFE barrier had to be removed prema-
turely, highlighting the importance of sufficient soft
tissue closure and timing of removal of the barrier.
The outcomes in these three cases were similar to the
control sites. Where healing was uncompromised, a
statistically significant difference was found after
6 months in width and height changes in favour of
the ARP group.
(b) GBR with membrane and ‘graft’
ARP resulted in statistically significantly less re-
sorption in width [21, 23] and height [23] in compar-
ison to unassisted socket healing. The histological
evaluation of the GBR procedures in the included
studies demonstrated new bone formation [21, 23],
but the presence of graft particles was also evident in
both studies, embedded either in newly formed bone
[21] or in connective tissue [23]. This is in agreement
with a recent trial, where a collagen membrane in
combination with DBBM or a biphasic bone substitute
was used for ARP [9, 10].
Biological active materials The potential benefit of biologi-
cal active molecules was investigated in periodontal and bone
regeneration through fostering the proliferation and differen-
tiation of different mesenchymal cells in various preclinical
models [63, 64]. The safety and feasibility of rhBMP-2 on
human ARP or ridge augmentation was evaluated and shown
to be safe in a two-centre clinical study [35]. Dimensional
changes of the alveolar ridge were measured on CT scans in an
RCT [20]. Treatment with recombinant BMP-2 resulted in an
increase in ridge width which was statistically significantly
greater than controls. However, this observation needs to be
Clin Oral Invest (2013) 17:341–363
interpreted in light of the surprise finding of an increase in
ridge width of the untreated controls. This was a unique
finding amongst the studies that we reviewed. Histologically,
no comparison between ARP and controls sites was reported.
The human histological results of the included papers of
the present review were generally found to be comparable to
preclinical studies [11–13, 60, 65]. There are a number of
aspects to consider in the interpretation of the results. First-
ly, it has to be kept in mind that whilst the biopsies of the
animal model incorporate the cross section of the whole AR,
the biopsy retrieval at human studies is limited to a trephine
core sample of part of the former socket. This location may
not necessarily coincide with the exact position of the pre-
vious extraction, thus making interpretation of the results
challenging. Furthermore, the differentiation between api-
cal, mid and coronal, as well as the central and lateral
aspects of the biopsies was not always apparent.
Another important parameter when considering a histo-
logical overview of the studies was the variation in healing
time. Due to the nature of post-extraction healing, the direct
comparison of the new tissue formation in studies between 1
and 9 months of healing could be misleading. This was
highlighted in three studies which did not make a distinction
between the variable healing times within the groups, rang-
ing from 2.5 months to 9 months [17, 21, 43]. It has to be
kept in mind also that the only study, which completed and
reported appropriate statistical methodology [47], did not
observe statistically significant difference between the test
and control biopsies.
Furthermore, small sample sizes in the majority of the
studies may also limit the generalisability of the histological
findings.
Two studies found statistically significant histological
differences in new bone formation favouring the test group
[21, 42]. Drawing conclusions across the studies is difficult
since the test groups differed in many respects compared
with each other, including different technique (bone sub-
stitute only [42]/GBR + graft [21]), different material
(MGCSH [42]/porcine bone with collagen membrane
[21]), different flap management (flapless, no primary clo-
sure [42]/mucoperiosteal flap, primary closure [21]), dif-
ferent healing time (3 months [42]/7–9 months [21]). One
common feature was that both groups limited their inter-
vention to sockets with four intact walls. It is noteworthy
that all three studies that included intact socket walls only,
reported statistically significant differences both on AR
width and height in favour of ARP [21, 42, 47], while only
one [20] out of two studies [19, 20] with initial buccal bone
loss reported similar significant difference between test
and control. Therefore, socket morphology could be an
important predicator of improved ARP. The need for
ARP in such sockets, in terms of future clinical success/
implant placement needs further investigation.
359
Flap management All studies reporting statistically signifi-
cant inter-group differences in both horizontal and vertical
clinical measurements achieved either primary flap closure
[21, 24, 25, 47], or did not detach the periosteum in a
flapless procedure [42]. Furthermore, none of the studies
without primary closure demonstrated statistically signifi-
cant differences between test and control in terms of both
horizontal and vertical clinical measurements [19, 23, 44].
Therefore, both achieving and maintaining the epithelial
seal above the socket may be crucial to improving ARP.
Further corroboration of this concept was suggested where
e-PTFE barriers were prematurely exposed. The healing of
these three exposed cases demonstrated no statistically sig-
nificant differences compared to the control sites [24].
Other factors affecting interpretation of the findings
Healing time
The optimal timing of re-entry following ARP is determined
by the implant insertion. Since the volume of the AR is
gradually decreasing, while the quality of the newly formed
tissue is gradually increasing during the post-extraction
remodelling [1, 6] the implant placement could be consid-
ered as early as possible, but as late as necessary, in order to
maintain AR volume, as well as to achieve complete epi-
thelial seal with some extent of osseous fill. The healing
periods of the trials in the present review varied consider-
ably (one to nine months). Therefore, interpretation of the
results was complicated by the heterogeneity present in the
included studies.
Antimicrobials
Improvement of clinical parameters was demonstrated as a
result of regular rinsing with chlorhexidine following tooth
extraction [66]. Subjects of the included trials in the present
review were prescribed various types of antibiotics and
instructed to rinse with chlorhexidine for 2 to 3 weeks.
Therefore, no conclusion could be drawn on the necessity
or benefit of employment of antibiotics/antimicrobials fol-
lowing ARP.
Smoking
Smoking is associated with delayed socket healing and
increased reduction in post-extraction alveolar width [67].
Three trials in this review included smokers [21, 23, 43] and
the half of the studies did not report on smoking as an
exclusion factor, thus any conclusions about the impact of
this well-recognised risk factor for impaired healing are
difficult to draw [68].
360
Periodontal treatment/health
Four studies included patients whose periodontal treatment
was carried out prior to the ARP [19, 21, 25, 48]. ARP
resulted in statistically significant difference between tests
and controls in clinical [21, 25] and in histological param-
eters [21]. In addition, in the studies where periodontitis was
present, but periodontal treatment was not reported, no
statistically significant histological differences were demon-
strated [43, 44, 46]. This suggests that treated periodontitis
may not hinder the success of ARP.
Hard and soft tissue morphology
No data were reported on factors, such as gingival biotype,
width of the keratinised gingiva, thickness of buccal plate or
total volume of AR that may modify the outcome of ARP.
Therefore, the possible impact of these factors on ARP
cannot be determined.
Clinical relevance
The clinical rationale for ARP is to minimise the necessity
for one or two stage alveolar ridge reconstruction to allow
successful implant placement. If the ARP procedure fails
to meet this requirement, it may be considered as an un-
necessary or even unsuccessful procedure. Therefore, a
statistical significance favouring ARP does not necessarily
lead to a clinical benefit, unless the whole treatment is
simplified or made more successful [9]. In the present
systematic review, seven out of ten studies did not report
differences in feasibility of implant insertion at re-entry
[17, 19, 23, 42, 45, 46, 48]. Only two studies reported that
there was no need for further reconstruction in the ARP
group, whilst GBR or ridge expansion were carried out in
some of the control sites alongside implant insertion [21,
47]. One study reported that statistically significantly less
augmentation had to be performed in the ARP group,
compared to the control [20]. In relation to illuminating
the understanding of possible long term benefits of ARP,
the success rate of the inserted dental implants in the
former test, versus control sites should be examined. No
studies have yet reported this.
Patient-reported outcome and health economics
It would be helpful to understand patient experiences such
as concomitant discomfort at/following ARP in order to
avoid a further, extensive reconstructive surgery. On the
other hand, the additional costs of ARP at the time of
extraction may not be desirable if the outcome and benefit
of such extra treatment were not predictable. There are no
data yet to inform on these questions.
Clin Oral Invest (2013) 17:341–363
Conclusions
Within the limits of the above findings the following con-
clusions can be drawn:
1. The results of the control groups confirm that tooth
extraction results in a statistically significant horizontal
and vertical resorption of the AR, as part of the natural
remodelling.
2. The magnitude of the horizontal shrinkage is more
pronounced than the vertical.
3. The resorption of the AR cannot be totally prevented
by ARP.
4. Dimensional changes of the AR may be limited by
some of the ARP techniques.
5. No evidence was identified to inform on the possible
impact of the following factors on ARP outcomes: (a)
site location, (b) buccal plate thickness, (c) healing
time, (d) antibiotic regime, (e) light smoking, (f) his-
tory of treated periodontitis.
6. The presence of intact socket walls and primary flap
closure are often associated with favourable results.
7. Conflicting evidence exists on the benefit of ARP
at the histological level. ARP does not appear to
promote de novo hard tissue formation routinely.
In addition, some graft materials may interfere with
healing.
8. Due to the broad variety of employed materials, tech-
niques, defect morphologies, healing periods, as well
as the relatively small sample sizes, meta-analysis or
comparative assessment of ARP cannot be made. Con-
sequently no material or method can be claimed to
serve superior to another. However, in certain cases
GBR appeared to be most effective.
9. Only limited evidence supports the clinical benefit of
ARP, namely the reduction of necessity of further
augmentation in conjunction with implant placement.
10. No evidence exists on comparison of the survival or
success rate of implants, placed in the former ARP or
control sites.
11. No evidence exists on cost-effectiveness, patient’s
preference or quality of life following ARP.
12. The case selection criteria for performing ARP remain
still undetermined.
13. The strength of evidence ranges from weak to moder-
ate and therefore, the conclusions of this review should
be interpreted with caution.
Recommendations for further research
& Randomised controlled trials on adequately powered
sample sizes are needed where unassisted socket healing
serves as the negative control.
Clin Oral Invest (2013) 17:341–363
& Appropriate follow-up periods are required. Ideally, this
should reflect implant insertion protocols, such as six
weeks (Type 2), three to four months (Type 3) or
>6 months (Type 4) placement following extraction.
& Clinical studies should be designed to perform not only
clinical (quantitative), but also histological (qualitative)
assessment.
& The role of additional factors like smoking, reason for
extraction, tooth location, initial buccal plate thickness,
flap reflection and closure, antimicrobial regime should
also be investigated.
& Comparative studies should also be designed in order to
identify the most successful treatment options.
& It may be beneficial to seek for a cell occlusive barrier
membrane that does not require extensive soft tissue
mobilization for flap approximation.
& Necessity of re-augmentation at implant placement
should be investigated.
& Survival and success rates of implants, placed in former
ARP sites should be evaluated.
& Outcome evaluation should ideally incorporate patient’s
preference, quality of life, as well as treatment economy.
Acknowledgments The authors wish to express their gratitude to
Aviva Petrie for her invaluable contribution to the statistical assessment.
Conflict of interest and source of funding There was no known conflict
of interest among the review team. The trial was self funded and supported
by the Research Discretionary Account of the Unit of Periodontology, UCL
Eastman Dental Institute. This work was undertaken at UCLH/UCL who
received a proportion of funding from the Department of Health’s NIHR
Biomedical Research Centres funding scheme.
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Ren E. Wang Ridge preservation after tooth extrac-
Niklaus P. Lang
tion

Authors’ affiliations: Key words: bone substitutes, GBR, implant dentistry, membrane, ridge preservation, tooth
Ren E. Wang, Niklaus P. Lang, The University of extraction
Hong Kong, Prince Philip Dental Hospital,

Corresponding author: Abstract

Prof. Niklaus P. Lang, DDS, MS, PhD, Dr, odont.
hc.mult.
Background: Following tooth extraction, the alveolar ridge will undergo dimensional changes.
The University of Hong Kong Faculty of Dentistry This change may complicate the subsequent restorative procedure when oral implants are chosen.
Prince Philip Dental Hospital, “Alveolar ridge preservation” has been assessed in various studies.
34 Hospital Road, Sai Ying Pun, Hong Kong SAR
PR China Aim: To evaluate the more recent studies on this topic and to explore new insights under this
Tel.: +852 2859 0526 topic.
Fax: +852 2559 9013 Material and methods: Animal studies and clinical studies have addressed different techniques.
Mobile: + 41 79 301 5505
e-mail: nplang@dial.eunet.ch Results and conclusions: Implants placed into the fresh extraction sockets do not prevent the
resorption of the alveolar bone. Simultaneous guided bone regeneration could partially resolve
Conflicts of interest: alveolar bone resorption. The use of root-formed implants does not preserve alveolar ridges.
The authors declare no potential conflicts.
Moreover, various bone substitutes have been tested: magnesium-enriched hydroxyapatite, human
demineralized bone matrix, and deproteinized bovine bone mineral have been shown to be
effective in ridge preservation. Applying the guided bone regeneration principle using bone
substitutes together with a collagen membrane has shown clear effects on preserving alveolar
ridge height as well as ridge width. Soft tissue grafts or primary closure did not show beneficial
effect on preserving the alveolar bone.

Following tooth extraction, the alveolar ridge
will undergo structural changes. These
changes in extraction sockets were amply
demonstrated with histological observations
in dog studies (Cardaropoli et al. 2003). At
day 1 after extraction, the socket was occupied
by a coagulum; this coagulum was comprised
mainly of erythrocytes and platelets that were
trapped in a fibrous matrix. Immediately adja-
cent to the hard tissue wall was the “bundle
bone”, and principal fibers from periodontal
ligament (Sharpey’s fibers) could be found
invested in the bundle bone. These were also
in direct contact with the coagulum. At day
3, the coagulum had been replaced by a richly
vascularized granulation tissue. At day 7,
newly formed blood vessels were evident in
the primary matrix. Various types of leuko-
cytes and collagen fibers had taken the place
of the residual periodontal ligament as well as
the granulation tissue. At day 14, most of the
bundle bone had disappeared, and instead,
adjacent to the newly formed blood vessels,
Date:
Accepted 03 July 2012 “woven bone” started extending from the old
bone of the socket walls toward the center of
To cite this article:
Wang RE, Lang NP. New insights into ridge preservation after the socket. At day 30, woven bone underwent
tooth extraction
resorption, suggesting that the remodeling
Clin. Oral Implants Res. 23(Suppl. 6), 2012, 147–156
doi: 10.1111/j.1600-0501.2012.02560.x process had begun. At day 60, hard tissue
bridges separated the marginal mucosa from
the socket, and bone marrow replaced woven
bone at the center of the previous socket. At
day 90, woven bone was replaced by lamellar
bone. At days 120 and 180, most of the woven
bone had been replaced by lamellar bone.
The role of bundle bone in the dimensional
change in the alveolar ridge was investigated in
several dog studies (Araùjo & Lindhe 2005;
Araùjo et al. 2005) At 1 week after extraction
(Araùjo & Lindhe 2005), the buccal bony crest
was 0.3 mm coronal to the lingual bony crest,
but at 2 weeks after extraction, the buccal crest
became 0.3 mm apical to the lingual crest.
This relative distance was increased to 0.9 and
1.9 mm at 4 and 8 weeks after extraction,
respectively. It was also observed that the cres-
tal region of the buccal bone wall was made up
exclusively of bundle bone, whereas the corre-
sponding region of the lingual bone was made
of a combination of bundle bone and lamellar
bone. Obviously, the function of bundle bone
is to anchor the tooth in the alveolar bone
through the invested periodontal ligament. As
the tooth is extracted, the bundle bone will lose
its function, and subsequently, will resorb.
This may explain the more pronounced resorp-
tion of the buccal than the lingual bony crest.

© 2012 John Wiley & Sons A/S 147

Wang & Lang
Ridge preservation revisited
A recent systematic review evaluated the
dimensional changes in the hard and soft tis-
sues of the alveolar process up to 12 months
following tooth extraction (Tan et al. 2012).
It was concluded that after 3 months of
healing, the horizontal resorption of the
alveolar bone was 2.2 mm at the crest, and
1.3, 0.59, and 0.3 mm at 3, 6, and 9 mm api-
cal to the crest, respectively; after 6 months
of healing, the vertical resorption of the
alveolar bone was 11–22%, whereas the hori-
zontal resorption of the alveolar bone was 29
–63%. When soft tissue was included
together with the hard tissue in the dimen-
sional assessments at 3 months of healing,
there was even an increase of 0.4 mm in the
vertical dimension. At 12 months of healing,
the vertical resorption of the alveolar ridge
was 0.8 mm. Horizontally, the resorption of
the soft and hard tissue together was 1.3mm
and 5.1mm after 3 and 12 months of heal-
ing, respectively.
This vertical as well as horizontal dimen-
sional changes of the alveolar ridge may com-
plicate the subsequent restorative procedures
when dental implants are chosen. Over the
past 20 years, increasing interest has arisen
regarding a concept called “alveolar ridge
preservation”, which was defined as “any
procedure undertaken at the time of or fol-
lowing an extraction that is designed to mini-
mize external resorption of the ridge and
maximize bone formation within the socket”
(Darby et al. 2008). As suggested by that
review, studies promoting various techniques
have been performed. Most of the studies
included the measurements of dimensional
changes of the alveolar ridge after a ridge
preservation procedure.
The purpose of this review was to evaluate
these more recent studies and to explore new
insights under this topic. Within the context
of exploring new insights for ridge preserva-
tion, also studies of lower levels in the
evidence hierarchy may be of interest to shed
some light on the techniques designed to pre-
serve the alveolar ridge after tooth extraction.
These low evidence papers are generally case
series that combine various protocols. How-
ever, this approach, should lead to clinical
validation before recommendable for routine
clinical application.
Animal studies
Implants for ridge preservation
Immediate implants alone
A decade ago, it was proposed that “early
implantation may preserve the alveolar anat-
148 | Clin. Oral Implants Res. 23, 2012 / 147–156
omy and that the placement of a fixture in a
fresh extraction socket may help to maintain
the bony crest structure” (Paolantonio et al.
2001). However, this statement has been
scrutinized later in a dog study (Araùjo et al.
2005). In the right jaw of five dogs, implants
were placed into the fresh extraction sockets,
while in the left jaw, fresh sockets were left
for spontaneous healing. After 3 months of
healing, histological sections were obtained
to assess the distance from the SLA level to
the first bone-to-implant contact under
microscope. On the buccal aspect, this dis-
tance was 2.6 mm at implant sites and
2.2 mm at the corresponding extraction
socket sites. Hence, the immediate place-
ment of dental implants clearly failed to pre-
vent the resorption of the buccal bone walls.
To further study the modeling of the buc-
cal bony plate, the same group of researchers
designed another dog study (Araùjo et al.
2006). In that study, the implants were
placed into the fresh extraction sockets in
the right jaw and 2 months later, the same
procedure was performed again in the left
jaw. Following another 1 month, the dogs
were sacrificed, and it was observed that after
1 month of healing, at the buccal aspect,
good osseointegration had been achieved
above the first thread of the implant. How-
ever, after 3 months of healing, the level of
this osseointegration had receded to below
the first thread as a result of the modeling of
the buccal bone. In the molar regions, the
degree of this modeling was much less
compared with the premolar regions, most
likely because of the wider original combined
defect and bone wall dimensions in the molar
regions. This study provided strong evidence
for the continued modeling process of the
buccal bony wall leading to buccal bone loss
despite the good osseointegration that had
already been achieved in early healing
phases. Obviously, this phenomenon was less
pronounced in sites with thicker buccal bony
walls. Again, immediate implant installation
failed to preserve the alveolar bone.
In a study aimed at observing bone-
to-implant contact of orthodontic implants
subjected to horizontal loading (Wehrbein
et al. 1998), immediately placed implants
with simultaneous horizontal loading
achieved better osseointegration than those
with delayed loading. Moreover, it was sug-
gested in another dog study that “a static
load may stimulate bone mineralization adja-
cent to titanium implants” (Gotfredsen et al.
2001). Finally, the hypothesis was tested
whether or not immediate implant place-
ment together with simultaneous loading
would help to preserve the buccal bone
(Blanco et al. 2011). In a dog model, two
implants were placed into the fresh extrac-
tion sockets at the premolar sites on each
side of the mandible. At the time of the
implantation, the implants on one side of the
jaw received a prosthesis with occlusal con-
tacts, while the implants on the other side
remained unloaded during the whole experi-
mental period. Three months later, the dogs
were sacrificed. The histomorphometric
results showed that the vertical distance
from the implant shoulder to the first bone-
to-implant contact was on average 3.66 mm
in the simultaneously loaded group and
4.11 mm in the unloaded group. This
difference was not statistically significant,
and hence it was concluded that “immediate
implant placement with or without loading
does not prevent bone resorption that occurs
following tooth extraction.”
Immediate implant with bone grafts
The effect of bone fillers (magnesium-
enriched hydroxyapatite) on preservation of
the alveolar bone around immediate implants
was evaluated in a dog study (Caneva et al.
2011). Implants with a sandblasted acid
etched surface (Zirti®, Sweden & Martina,
Due Carrare, PD, Italy) were placed into the
fresh extraction sockets bilaterally in the
dogs’ jaws. The margin of the rough surface
was placed at the level of the buccal bony
crest. On one side of the jaw, the bone filler
was applied into the gaps around the
implants. The contralateral sites were left
unfilled as controls. After 4 months of sub-
merged healing, the dogs were sacrificed. His-
tomorphometric evaluations showed that the
vertical distance from the junction between
rough and smooth surface to the buccal bony
crest was on average 0.7 mm in the group
with the bone filler and 1.2 mm in the
control group with no statistically significant
differences between the groups. Obviously,
the use of bone fillers around implants
immediately placed into extraction sockets
did not contribute significantly to the preser-
vation of the buccal bone. In a recent experi-
ment (Araújo et al. 2011), it has been
demonstrated that the use of Bio-OssÒ col-
lagen as a bone substitute filler in the space
between the implant and the buccal bony
wall resulted in the prevention of buccal soft
tissue recession and a reduction in peri-
implant bone loss and allowed the buccal
bone to be thicker at the marginal level.
However, another similar animal study
(Favero et al. 2012) was not able to confirm
these differences in outcomes.
© 2012 John Wiley & Sons A/S

Immediate implant with GBR
In an AAP-commissioned review on bone
augmentation techniques, it was recom-
mended that immediate implant placement
together with GBR techniques may yield out-
comes comparable to delayed placed implants
(McAllister & Haghighat 2007). Recently,
a dog study was conducted to evaluate the
influence of absorbable membranes on hard
tissue alterations around the immediately
placed implants (Caneva et al. 2010a,b,c).
Implants with a rough surface (zirconium
sandblasted acid etched) were placed immedi-
ately following extraction on both sides of
the mandibles, on the test side of the jaw,
collagen resorbable membranes were placed
to cover the implants. On the control side of
the jaw, the implants were left without
membranes.
After 4 months of intended submerged
healing, all implants were found exposed to
the oral cavity because of soft tissue dehi-
scences. The dogs were sacrificed and biop-
sies were obtained. The distance between the
most coronal margin of the implant and the
bone crest were measured. At the buccal
aspect, this distance was 1.7 mm on the
implants placed with GBR procedures, and
2.2 mm on the implants placed without
GBR, and this difference was statistically sig-
nificant. At the lingual aspect, this distance
was 0.6 and 0.4 mm on the test sites and
control sites, the difference not reaching sta-
tistical significance. There was no difference
between the groups regarding the level of
first bone-to-implant contact and the percent-
age of bone-to-implant contact. This study
provided evidence that the use of collagen
resorbable membranes at immediate implant
sites contributed partially (23%) to the pres-
ervation of the buccal bony wall.
Further studies of the same group of
researchers (Caneva et al. 2011, 2012)
explored the effect of GBR based on deprotei-
nized bovine bone mineral on alveolar ridge
preservation and the reparation of defects
around osseointegrated implants. After
hemi-sectioning the third mandibular premo-
lars and extracting the distal roots, a recipi-
ent site was prepared for an implant. This
was placed lingually, leaving a defect of
about 0.6mm in width and 3mm in depth at
the buccal aspect. While the other side of
the jaw was used as control without GBR,
deproteinized bovine bone mineral (DBBM)
was place into the defects of the test site and
covered with a collagen membrane. This
treatment contributed to improved bone
regeneration in the defects. However, regard-
ing the buccal bony crest preservation only a
© 2012 John Wiley & Sons A/S
limited contribution of DBBM particles was
obtained (Caneva et al. 2011).
In the second study on the same material
the dimensional changes of the alveolar bony
crest following the placement of DBBM parti-
cles into sockets immediately after tooth
extraction, in conjunction of the placement
of a collagen membrane, were addressed
(Caneva et al. 2012). After 4 months of heal-
ing, no differences in soft tissue dimensions
were found based on histological evaluations.
Yet, the location of the soft tissue at the buc-
cal aspect was more coronally at the test
compared to the control sites. Hence, it was
concluded that the application of DBBM con-
comitantly with the placement of a collagen
membrane at implant sites placed in the
socket immediately after tooth extraction
contributed positively to the preservation of
the alveolar process.
In a similar study recently published (Park
et al. 2011), immediate implants (Institute
Straumann AG, Basel, Switzerland) were
placed bilaterally in the dogs’ jaws in the pre-
molar region. On the experimental side, a
non-resorbable ePTFE membrane (Tefgen®,
Lifecore Biomedical, Chaska, MN, USA) was
placed on the buccal plate of the implant
sites without coverage of the bone crest and
was fixed with mini screws. In the control
site, no membrane was placed. After
3 months of non-submerged healing, no
membrane exposure occurred. The dogs were
sacrificed and after histometric observation,
the vertical distance from the rough and
smooth surface interface to the buccal bone
crest was on average 1.72 mm in the control
group and 0.92 mm in the experimental
group. This difference was statistically signif-
icant. Moreover, at the level 2 mm below the
buccal bony crest, the mean thickness of the
buccal bone walls was 0.4 mm in the control
group and 1.49 mm in the test group. Again,
this difference was statistically significant.
From the above two animal studies, it
appeared that the outcomes of using non-
resorbable ePTFE membranes is superior to
that achieved by resorbable collagen mem-
branes. It should be realized that the tech-
niques applied in the two studies were
different. In the first study, the resorbable
collagen membranes were placed on top of
the implants without fixation, and primary
closure was achieved at the completion of
the surgery. However, during the healing per-
iod, all implants were exposed because of soft
tissue dehiscences. In the later study, the
non-resorbable membrane was placed on the
buccal bone wall and fixed with mini screws
to avoid membrane exposure. The mem-
Wang & Lang
Ridge preservation revisited
branes were placed below the buccal bony
crests, and no primary closure was intended,
which meant that the flaps healed without
tension. Consequently, membrane exposure
was absent during healing.
Shape of implants and implant positioning
Tapered or root-formed implants were
designed to reduce the gaps around implants
that were placed immediately into the fresh
extraction sockets, thus filling the defect par-
tially with titanium. The question arises if
this type of implant design will help in pre-
venting alveolar bone resorption around such
implants. In a split-mouth design, mandibles
of dogs received cylindrical implants 3.3 mm
in diameter (Premium®, Sweden & Martina,
Due Carrare, PD, Italy) immediately after
tooth extraction (control) (Caneva et al.
2010c). A similar procedure was carried out
with root-formed implants 5 mm in diameter
(Kohno®, Sweden & Martina, Due Carrare,
PD, Italy) on the test sites. After 4 months of
non-submerged healing, the dogs were sacri-
ficed and histomorphometric evaluations
were performed. The mean vertical buccal
bone resorption was significantly greater in
the test group (2.7 mm) than in the control
group (1.5 mm). In essence, the filling of gaps
with root-formed implants failed to preserve
the buccal bone. On the contrary, the bone
resorption was more pronounced around the
root-formed immediate implants that filled
the extraction socket to a greater extent than
did the cylindrical implants. The root-formed
implants with a wider diameter occupied the
entire socket, leaving no space between the
implant and the buccal bony wall. In other
words, the implant body was located closer
to the outer surface of the buccal bony wall.
Consequently, a greater portion of the
implant was exposed in the supracrestal
region after modeling and remodeling pro-
cess, as the distance between the implant
outline and the outer surface of the buccal
bone appears to be a crucial factor for the
preservation of the buccal bone.
To evaluate the influence of implant posi-
tioning into extraction sockets on the main-
tenance of the buccal bone level (Caneva
et al. 2010a), implants (Premium®, Sweden &
Martina, Due Carrare, PD, Italy) were placed
in the center of the sockets in control sites
of mandibles, whereas in the test sites, the
same implants were placed 0.8 mm deeper
and more lingually. After 4 months of non-
submerged healing, the histometric evalua-
tions showed that the mean vertical distance
from the rough and smooth surface interface
to the buccal bone crest was significantly less
149 | Clin. Oral Implants Res. 23, 2012 / 147–156
Wang & Lang
Ridge preservation revisited
in the test group (0.6 mm) compared with
the control group (2 mm). Hence, the posi-
tion of the implant had a greater impact on
the preservation of the buccal bone resorp-
tion than the shape of the implant.
Bone substitutes
Bone substitutes alone
The effectiveness of ridge preservation with
bone grafting in the extraction sockets alone
was evaluated in a dog study (Boix et al.
2006). The maxillary and mandibular premo-
lars were extracted. The sockets of the distal
roots were filled with an injectable bone sub-
stitute (a polymer solution and granules of a
biphasic calcium phosphate ceramic), and the
sockets of the mesial roots were left unfilled
as controls. Primary closure was achieved by
overlapping hermetic sutures. After 3 months
of healing, a tangent vector was drawn con-
necting the buccal and lingual crests, and the
distance from the highest point of the alveo-
lar ridge and this tangent vector was mea-
sured. There was a significant difference
between the groups in the mandible (0.5mm
and 0.4mm in test and control, respectively)
and the maxilla ( 0.3 and 0.5 in the test
and control, respectively).
In another dog study (Shi et al. 2007), man-
dibular premolars and molars were extracted,
the extraction sockets on the test side were
treated with Surgical-Grade Calcium Sulfate
(SGCS) + platelet-rich plasma (PRP) or with
SGCS alone. On the control side, the sockets
were left unfilled. Primary closure was
achieved by periosteal releasing incisions and
coronally advanced flaps. At baseline and
2 months after healing, CT scans were taken.
Alveolar bone height was assessed on CT
scans as the distance from the midpoint of
the cortical bone to the inferior border of the
mandible. It was found that the reduction in
the ridge height was significantly greater in
the control group compared with the test
group (2.77, 1.39 mm, respectively), although
no difference was found between SGCS +
PRP treatment and SGCS treatment alone.
In five beagle dogs (Fickl et al. 2008a,b),
the 3rd and 4th mandibular premolars were
extracted. In the test sites, the sockets were
filled with Bio-Oss® collagen (Geistlich
Biomaterials, W olhusen, LU, Switzerland).
The collagen was fixed with sutures. The
control sites were left untreated. After
4 months of healing, the histomorphometric
evaluation documented a mean vertical buc-
cal bone loss that was significantly lower in
the test (2.8 mm) than in the control sites
(3.2 mm). At 1 mm below the crest, the
150 | Clin. Oral Implants Res. 23, 2012 / 147–156
untreated group had a significantly narrower
ridge width than the test group (3.7 mm vs.
4.4 mm). However, at 3 mm/5 mm below
the crest, the ridge width was similar
between the groups. Using digital image anal-
ysis on study casts for the same material
(Fickl et al. 2008a,b) at the buccal aspect, the
volumetric differences from baseline to after
4 months of healing was significantly greater
in the control group (-2.2mm) than the test
group (-1.5mm). These results showed small
benefits toward using Bio-oss® collagen.
A similarly designed study (Araùjo & Lind-
he 2009) compared sockets healing without
treatment (control) and sockets treated with
Bio-oss® collagen (test). Flaps were coronally
replaced and primary closure was achieved in
both types of sockets. After 6 months of
healing, biopsies were obtained. Histometric
analysis revealed that the dimensional
changes in the apical and middle portion of
the sockets were moderate in both sites, but
in the coronal portion, the ridge width reduc-
tion was three times greater in the control
sockets ( 35%) compared with the test sock-
ets ( 12%). However, the composition
between two sites was similar. The xenograft
(Bio-Oss®, Geistlich Biomaterials, W olhusen
LU, Switzerland)) only served as a scaffold and
did not stimulate new bone formation.
Another histometric study (Rothamel et al.
2008) compared sockets treated by Nanocrys-
talline hydroxyapatite paste (test) with un-
filed sockets (control). Primary closure was
achieved in both groups. After 3 and
6 months of healing, the dogs were sacrificed.
Histometric analysis on lingual and buccal
bone height, alveolar wall, and total bone
width showed no difference for any parame-
ters between groups. It could be concluded
that Nanocrystalline hydroxyapatite paste
does not appear to be effective for ridge pres-
ervation.
Xenografts versus autografts
For many years, the use of autologous bone
was regarded as a “gold standard” for augmen-
tation procedures. To evaluate its efficacy in
ridge preservation, a dog study was conducted
(Araùjo & Lindhe 2011). Extraction sockets in
the mandibles of dogs were filled with either
anorganic bovine bone or autogenous bone
chips. After 3 months of healing, a histomet-
ric analysis was performed. The cross-sec-
tional area of the ridge alteration was
estimated by subtracting the cross-sectional
ridge area identified after extraction from the
corresponding area at the adjacent root. In the
apical and middle portions of the sockets, no
resorption was observed. However, in the
coronal portions, the ridge underwent resorp-
tion ( 25%) in the autogenous bone graft
group. In the xenograft group, there was a posi-
tive change (3.6%). The residual grafting mate-
rial was found to be 24.4%. Non-vital
autogenous bone chips were found to be 1.9%.
It seemed that autologous bone did not pre-
serve the alveolar ridge.
Primary flap closure
Soft tissue grafts versus no soft tissue grafts
In five beagle dogs, the 3rd and 4th mandibu-
lar premolars were extracted (Fickl et al.
2008a). In the test group, the sockets were
filled with Bio-oss® collagen, and free gingi-
val grafts were obtained to cover the sockets.
The control sites were also filled with
Bio-oss® collagen (Geistlich Biomaterials, W
olhusen, LU, Switzerland). The collagen was
fixed with sutures, but no soft tissue grafts
were applied. After 4 months of healing, the
histomorphometric evaluation showed a
mean vertical buccal bone loss that was sig-
nificantly lower in the control group
(2.8 mm) than in the test group (3.3 mm). At
1mm below the crest, the control group had
significantly narrower ridge width than the
test group (4.4 mm vs. 4.8 mm). But at
3 mm/5 mm below the crest, the ridge width
was similar between the test and control
groups. In another study digital image analy-
sis on study casts from the same material
(Fickl et al. 2008b), the remodeling process at
the buccal aspect from baseline to after
4 months of healing was similar between the
control and test groups ( 1.5 mm vs. 1.6
mm). These results, therefore, indicate the
need for further human research using free
gingival grafts to obtain primary closure for
alveolar ridge preservation in well preserved
alveoli.
Clinical trials
Implants for ridge preservation
Immediate implants alone
To observe the alteration of hard tissues fol-
lowing tooth extraction and immediate
implant placement, a clinical study was con-
ducted (Botticelli et al. 2004). In 18 patients,
21 SLA surface implants were placed. After
4 months of non-submerged healing without
loading, a re-entry surgery was performed.
The differences between the clinical mea-
surements made before implant placement
and after 4 months of healing yielded a hori-
zontal resorption of the buccal bone of about
56%. The corresponding resorption of the lin-
© 2012 John Wiley & Sons A/S

gual/palatal bone was 30%, whereas the ver-
tical bone resorption was on average 0.3 mm
at the buccal aspect and 0.6 mm at the lin-
gual/palatal aspect. This amount of resorp-
tion is very similar with the resorption at
human alveolar ridges after extraction
reported recently in a systematic review (Tan
et al. 2012). This, in turn, means that
implants immediately placed into extraction
sockets, also in humans, do not prevent the
resorption of the alveolar bony ridge.
Immediate implant with bone GBR
The effect of membrane placement in con-
junction with or without bone substitutes for
preserving the alveolar bony around implants
immediately placed into extraction sockets of
the anterior region (Chen et al. 2007) was
studied in 30 patients that randomly received
immediate implants (SLA surface, Institute
Straumann AG, Basel, Switzerland) with Bio-
oss® + collagen membrane (Geistlich Bioma-
terials, W olhusen, LU, Switzerland), Bio-oss®
alone, or were left un-grafted. The dimen-
sions of the alveolar bony crest were assessed
at baseline and at the re-entry surgery after
6 months of healing. The implants were
loaded after further 2 months, and the
patients were followed up to 3 years after
completion of restoration delivery. Standard-
ized peri-apical radiographs and peri-implant
examinations were performed every year. At
the re-entry surgery, there was no significant
difference between the groups on the vertical
and horizontal defect reduction around the
implants. On the other hand, the reduction
in the horizontal distance from the outer sur-
face of the buccal bony ridge to the implant
surface was significantly greater in the con-
trol group (48.3 ± 9.5%) than in the bone
graft alone group (15.8 ± 16.9%) and the bone
graft with membrane group (20 ± 21.9%).
During the 3-year post-restorative follow-up,
all patients kept excellent oral hygiene. No
difference was found regarding the peri-
implant or radiographic parameters between
baseline and 1-year/3-year follow-ups or
among the groups. This clinical study dem-
onstrated that the bone defect around the
immediately placed implants will heal pre-
dictably irrespective of the usage of mem-
branes or bone grafts. However, the
membrane or bone graft treatment may
reduce the horizontal resorption of the buccal
bony plate by 25% of the original dimension.
Another clinical study was performed in
the molar region, to examine the alteration
of the alveolar bony ridge around implants
immediately placed into molar extraction
sockets after 6 months of healing (Matarasso
© 2012 John Wiley & Sons A/S
et al. 2009); 12 immediate transmucosal
implants with an sandblasted acid etched
surface were placed in 12 patients. GBR was
performed by placing a resorbable collagen
membrane supported by a bone substitute
(Bio-oss®). The alveolar bone dimensions
around the implants were assessed at the
time of implant surgery and at the re-entry
surgery after 6 months of healing. The gaps
around the implants healed as expected.
However, the horizontal distance from the
outer surface of the alveolar ridge to the
implant surface at the buccal aspect was
reduced by 58% on average. Unfortunately,
no control group was provided in this study.
An interesting aspect of this study was the
influence of bone thickness on the buccal
bone resorption. If the buccal bony wall was
initially 1-mm thick, the buccal bone resorp-
tion was as high as 52%. However, when the
buccal bone wall was initially 2-mm thick,
the buccal bone resorption was significantly
reduced to 33%.
Shape of implants and implant positioning
As one of the proposed benefits of using root-
formed implants was to avoid the need for
bone augmentation, a multi-center random-
ized controlled clinical trial was conducted to
test this hypothesis (Lang et al. 2007). In nine
centers, 216 patients received either cylindri-
cal or tapered implants (Institute Straumann
AG, Basel, Switzerland) installed into the
extraction sockets in non-molar regions. Dur-
ing the surgery, the type of implants was allo-
cated at random and the need for guided bone
regeneration was assessed. Whenever the gap
around the implants was more than 0.5 mm
or whenever buccal bony plate was thin (less
than 1 mm), augmentation procedures were
performed. Questionnaires were given to both
patients and the operators to assess the prefer-
ence to these two types of implants. The
results revealed that 90% of both implant
designs required GBR procedures. Patient-
reported outcomes did not show any prefer-
ence toward any type of the implants. How-
ever, the surgeons’ perception was in favor of
the tapered implants. Therefore, it is evident
that root-formed implants do not offer an
advantage in the need for avoiding GBR
procedures.
Another multi-center study aimed to a com-
parison of the dimensional bony changes
around the two types of implants (Sanz et al.
2010). The hypothesis of the study was that,
by providing more space for the coagulum
around the implants, the cylindrical implants
(test) should have a positive effect in preserv-
ing the alveolar bone and to reduce the hori-
Wang & Lang
Ridge preservation revisited
zontal bone resorption by 20% when
compared with the tapered implants (control).
In three centers, 93 patients were included in
the study. Forty-five cylindrical implants
(Astra Tech AB, Mölndal, Sweden) were
installed into extraction sockets in the test
group, and 48 tapered implants (Astra Tech
AB, Mölndal, Sweden) were placed in the con-
trol group. At baseline and at the re-entry sur-
gery after 4 months healing, the results
indicated that there was a marked reduction
in the distance from the outer surface of the
ridge to the implant in both groups (43% and
30%, respectively), although this difference
was not statistically significant. Once again, it
was evidenced that tapered implants cannot
preserve the alveolar bony ridge. On the con-
trary, tapered implants were associated with
more bone resorption.
Non-surgical treatment
Ultrasonic non-surgical treatment
The effect of ultrasonic application on bone
healing has been studied in the orthopedic lit-
erature. In vitro experiments showed a signifi-
cant influence of ultrasound on the
proliferation of mandibular osteoblasts. Clini-
cal evidence has also demonstrated that ultra-
sound treatment may accelerate the healing
process of tibial diaphysis fractures by 38% in
time (Kerr et al. 2008). In a randomized con-
trolled split-mouth clinical trial, 12 patients
who were scheduled for tooth extraction on
both sides of the jaw were enrolled. At 7–
10 days following extraction, ultrasound ther-
apy was delivered on the alveolar ridge of the
test site for 20 min using a piezoelectric
transducer for 10 sessions over the subsequent
4 weeks. Standardized cone-beam volumetric
tomography (CBVT) scans were acquired at
baseline (7–10 days post extraction), comple-
tion of ultrasound therapy (4 weeks after ther-
apy), and 3 months post extraction.
Dimensional changes of the buccal and lin-
gual bony plates were analyzed through
CBVT. However, given the limitations of
small sample size and a short observational
period with CBVT scans in this study, no sig-
nificant differences could be found in absolute
bony dimensional changes.
Bone substitutes
Bone fillers alone
In a randomized controlled clinical trial (Nei-
va et al. 2008), the effectiveness of an
anorganic bovine-derived hydroxyapatite
matrix delivered in a putty-form combined
with a synthetic cell-binding peptide P-15
151 | Clin. Oral Implants Res. 23, 2012 / 147–156
Wang & Lang
Ridge preservation revisited
(Putty P15) on ridge preservation was investi-
gated. Comparisons were made between
untreated control sockets and sockets treated
with this putty-form matrix (test). Collagen
dressing material was applied in both groups.
After 4 months of healing, at the re-entry
surgery, no difference was found between the
groups in ridge width reduction ( 1.31 and
1.43mm in test and control, respectively).
However, significantly less ridge height
reduction was found in the test group
(0.15 mm) compared with the control group
( 0.56 mm). The bone density assessed dur-
ing implant surgery was found significantly
higher in the test group as well.
Another biomaterial, medical-grade calcium
sulfate hemihydrates (MGCSH) was evaluated
in a randomized controlled clinical trial (Ai-
metti et al. 2009). In the test group, 22
patients received this material in their sock-
ets. As control group, 18 patients did not
receive any treatment after extraction at all.
Clinical measurements were performed at
baseline and at the re-entry surgery (implant
surgery). After 3 months of healing, signifi-
cantly greater reduction in ridge height was
found in the control group (1.2 mm) compared
with test group (0.5 mm). Moreover, signifi-
cantly greater ridge width reduction was found
in the control group (3.2 mm) compared with
the test group (2.0 mm). A histological analy-
sis also found less lamellar bone and more
woven bone in the control group.
Two new materials were evaluated in a
split-mouth clinical trial (Crespi et al. 2009).
In 15 patients, three teeth were extracted in
each patient. One of the sockets was treated
with magnesium-enriched hydroxyapatite
(Test 1). Another socket was treated with
Calcium sulfate (Test 2). The third socket
was left unfilled (control). The filling materi-
als in the two test groups were secured with
a collagen sheet covering and sutures to affix
the membrane. Applying standardized intra-
oral radiographs obtained at baseline and
3 months later at the re-entry surgery, signif-
icant differences in ridge height reduction
was found among all groups ( 0.48, 2.48,
and 3.75 mm in the Test 1, Test 2, and
control group, respectively). In histological
analyses, the amount of vital bone was found
to be significantly different among all groups
(40.0, 45.0, and 32.8% in the Test 1, Test 2,
and control group, respectively). The amount
of connective tissue was not different
between the test groups, but it was signifi-
cantly different between the test and control
groups. Significantly, less residual grafting
material was found in sockets treated with
Calcium sulfate. Based on this study, magne-
152 | Clin. Oral Implants Res. 23, 2012 / 147–156
sium-enriched hydroxyapatite was found to
be more useful in alveolar ridge preservation
than calcium sulfate.
In a recent clinical split-mouth design
study (Fernandes et al. 2011), sockets treated
with anorganic bovine bone matrix (ABM)
+ synthetic cell-binding peptide P-15 (Test)
were compared with unfiled sockets (control).
The sockets in both groups were covered
with Acellular dermal matrix (ADM). Clini-
cal measurements were made at baseline and
after 6 months of healing. No statistically
significant differences could be found on
ridge height reduction between the groups
(1.5 and 1.2 mm in the control and test
groups, respectively). But the ridge width
resorption was significantly greater in the
control (3.40 mm) compared with the test
group (2.52 mm).
The effectiveness of an allograft material
in ridge preservation was recently tested in a
randomized controlled clinical trial (Brown-
field & Weltman 2012). Twenty patients
were divided into two groups. The extraction
sockets in the test group were treated with
an allograft paste composed of “osteoinduc-
tive” demineralized bone matrix and cancel-
lous bone chips, and the sockets in the
control group were left unfilled. The sockets
in both groups were covered with an absorb-
able collagen wound dressing. No significant
difference on ridge resorption was found
between the two groups as studied by CBCT/
Micro CT and histological analysis, although
CBCT analysis found a significant correlation
between initial buccal bony plate thickness
and loss of ridge height.
Different particle size
In general, smaller particles of bone substi-
tutes are preferred because they may be
resorbed more rapidly. They may enhance
osteogenesis because of a greater surface area.
On the other hand, the optimal particle size
may depend on the bony defect to be grafted.
Extraction sockets may benefit more using
larger particles, as the sockets are usually lar-
ger than the periodontal defects.
To elaborate on the most appropriate parti-
cle size to be used in extraction sockets, a
randomized controlled clinical trial was
conducted (Hoang & Mealey 2012) in 20
patients. One molar was extracted in each
patient. The sockets were either filled with
human demineralized bone matrix (DBM)
putty with a single particle size (2–4 mm) or
with multiple particle sizes (125–710 lm).
Clinical assessments of the ridge dimensions
were made at baseline and at re-entry surgery
after 4–5 months of healing. No difference
was found on ridge width reduction between
the single particle size group (1.4 mm) and
multiple particle size group (1.3 mm). The
vertical buccal and lingual bone loss was less
than 0.5 mm in both groups. Histological
analysis did not find any difference between
the groups. Obviously, ridge preservation
using this grafting material irrespective of its
particle sizes was effective.
Demineralized allografts versus mineralized allografts
Although both demineralized freeze-dried
bone allograft (DFDBA) and mineralized
freeze-dried bone allograft (FDBA) are claimed
to be osteoconductive; only DFDBA has been
proven to be osteoinductive. Both DFDBA
and FDBA contain bone morphogenic pro-
teins (BMP). As the process of demineraliza-
tion facilitates the release of soluble factors
like BMP, evidence suggested that a maxi-
mum of osteoinduction was observed when
there was approximately 2% residual calcium
in DFDBA. However, FDBA may serve as a
superior scaffold compared with DFDB for
space maintenance and may also be more os-
teoconductive. When osteoclasts break down
the mineral content in FDBA until it is also
demineralized, there could be a prolonged os-
teoinductive effect. To evaluate the clinical
effectiveness of these two materials on ridge
preservation, a randomized controlled clinical
trial was performed (Wood & Mealey 2011).
Forty patients were randomly allocated into
two groups. The extraction sockets of the
patients were filled with FDBA or DFDBA,
respectively. All grafting materials were
obtained from a single donor. Clinical mea-
surements were performed at baseline and at
re-entry surgery after 4–5 months of healing.
No difference between the groups was found
on ridge height reduction (1 mm in both
groups) or ridge width reduction (2 mm in
both groups). However, histological analysis
yielded that the vital bone content was signif-
icantly higher in the DFDB group (38.42% vs.
24.63%), while the residual graft content was
significantly lower in DFDBA group (8.88%
vs. 25.42%). Although DFDBA may seem to
be more osteoinductive, its effect on ridge
preservation is similar to that of FDBA.
Synthetic bone substitutes versus xenografts
Bone Ceramic® is a biphasic ceramic bone
substitute. It is composed of a combination
of hydroxyapatite (HA) and b-tricalcium
phosphate (b-TCP). HA is insoluble.
Although it is well tolerated in bone, its os-
teoconductive properties have been ques-
tioned. To be osteoconductive, the material
should leave space for new bone to be depos-
© 2012 John Wiley & Sons A/S

ited. Unlike HA, b-TCP is soluble. When it
slowly resorbs, it is replaced by new bone.
The objective of combining the insoluble HA
with b-TCP, therefore, is that HA would
maintain the space (scaffold function), while
the b-TCP would resorb and promote new
bone formation.
A randomized controlled clinical trial was
conducted to compare the ability of preserving
alveolar ridges with this synthetic material
(Bone Ceramic®,Institute Straumann AG,
Basel, Switzerland) and a xenograft material,
deproteinized bovine bone mineral (DBBM)
(Mardas et al. 2010). Thirty patients were ran-
domly assigned to two groups. One non-molar
tooth in each patient was extracted, and the
sockets in one group were filled with Bone
Ceramic®, whereas in the other group, the
sockets were filled with DBBM. A resorbable
bi-layer collagen membrane was applied to
cover each socket. Flaps were coronally
advanced to close the wound as well as possi-
ble. Clinical assessments on ridge dimensions
were made at baseline and at re-entry surgery
after 8 months of healing. The reduction in
the ridge width was significantly less in the
Bone Ceramic® group ( 1.1 mm) than in
DBBM group ( 2.1 mm). The reduction in the
ridge height was negligible in both groups.
Both materials partially preserved the width
and interproximal bone height of the alveolar
ridge. Bone Ceramic® achieved a better out-
come in preserving the alveolar ridge. In a
clinical study (De Coster et al. 2011), whereby
bone regeneration in healing extraction sock-
ets substituted with Bone CeramicÒ was com-
pared with unfilled sockets, biopsies were
obtained from the sites during later performed
implant bed preparation. Healing was evalu-
ated using transmitted light microscopy after
6–74 weeks (mean 22 weeks). 15 Bone cera-
micÒ sites were compared with 10 naturally
healed sockets. During implant placement it
was clinically observed that bone at the sub-
stituted sites was softer than in control sites
and large amount of loose biomaterial were
found requiring thorough debridement. Con-
sequently, some of the recipient beds were too
large to get normal diameter implants initially
stable. Hence, wider implants were necessary,
and in 4 substituted sites, implants could not
be installed at all. Additionally, it was
reported that 2 out of ten implants installed in
substituted sockets failed within 3 months
after insertion. The histology showed that 5/
15 substituted sites showed clearly incom-
plete healing. Overall, new bone formation
was consistently poorer than in controls and
presented with predominantly loose connec-
tive tissue and less woven bone. The grafting
© 2012 John Wiley & Sons A/S
material appeared to interfere with the normal
healing process. Hence, using this material for
crestal bone preservation when implants are
considered, even after long healing time,
should be revised and based on additional
scientific studies.
Collagen plugs
Ideally, ridge preservation procedures should
be easy and should not involve additional
surgery. The use of collagen plug was intro-
duced, as it has the mentioned advantages.
To test its effectiveness on preserving alveo-
lar ridges, a randomized controlled clinical
trial was conducted (Kim et al. 2011).
Twenty patients were divided into two
groups. After the extraction of one molar in
each patient, the sockets in one group were
grafted with Bio-oss® and a collagen plug.
Sutures were applied to fix the material. The
sockets in the other group were left unfilled
as controls. Study casts were obtained imme-
diately at baseline and after 3 months of
healing. Assessments of the bony height and
ridge width were performed. After calcula-
tion, the average resorption rate of the bone
height was 6.8% in the control group and
5.8% in the test group. There was no signifi-
cant difference between the groups. The aver-
age resorption rate of the alveolar ridge width
at 3 mm below the crest was 20.7% in the
control group and 14.3% in the test group.
Although this technique may be advanta-
geous in preserving the alveolar ridge, no def-
inite recommendations may be made.
Collagen plugs with soft tissue grafts
To evaluate the effectiveness of a collagen
plug together with soft tissue graft on ridge
preservation (Oghli & Steveling 2010), 125
patients were divided into three groups. After
tooth extraction, the sockets were treated
with either a cone comprised of collagen (Test
1), a cone comprised of collagen and impreg-
nated with gentamicin (Test 2), or left unfilled
(control). In the two test groups, soft tissue
grafts were harvested from the palate, and the
sockets were covered with the sutured grafts.
Study casts were obtained at baseline and after
3 months of healing. Assessments of the verti-
cal dimension of the alveolar ridge were made
on the casts. No difference was found among
the three groups on vertical ridge resorption
(0.8, 0.1, and 0.3 mm in Test 1, Test 2, and
control groups, respectively). However, cau-
tion should be taken while interpreting these
results. While using study casts to measure
the ridge dimensions, soft and hard tissue
alterations are included as indicated in a sys-
tematic review (Tan et al. 2012). Soft tissue
Wang & Lang
Ridge preservation revisited
may increase in dimension to partially com-
pensate the hard tissue resorption, especially
in vertical direction. Hence, the assessment of
study casts may not be appropriate to evaluate
the effectiveness of ridge preservation proce-
dures.
Guided Bone Regeneration (GBR)
Ridge preservation with or without GBR
A cohort study was performed to follow 30
patients who received ridge preservation pro-
cedures with resorbable b-TCP of small parti-
cle size and resorbable collagen barriers after
tooth extraction (Horowitz et al. 2009). Eval-
uating clinically the alveolar ridge width at
baseline and at re-entry surgery 6 months
later, a mean reduction in the ridge width of
12.4% was reported. Although there was no
control group, it could be estimated from his-
torical controls of a systematic review that
reported on horizontal ridge resorption at
6 months after extraction (29–63%) (Tan
et al. 2012) that this ridge preservation proce-
dure applying the guided tissue regeneration
principle was certainly effective.
In a randomized controlled clinical trial (Ba-
rone et al. 2008), 40 patients were randomly
allocated into two groups. After tooth extrac-
tion, the sockets of the patients in test group
received guided bone regeneration procedures
with cortico-cancellous porcine bone and col-
lagen membranes. The sockets of the patients
in the control group were left to heal sponta-
neously. Clinical measurements were per-
formed at baseline and at re-entry surgery
after 7 months of healing. It was found that
the reduction in ridge width and height were
significantly lower in the GBR group com-
pared with control group (2.5 mm vs. 4.5 mm;
0.4 mm vs. 3 mm, respectively). Histological
analysis revealed that the amount of cancel-
lous bone was significantly greater in the GBR
group (35.5% vs. 25.7%), and the amount of
connective tissue was significantly less in the
GBR group (36.6% vs. 59.1%).
Membranes versus no membranes
To evaluate the adjunctive effect of resorb-
able collagen membranes to bone substitutes,
a randomized clinical study was conducted
(Brkovic et al. 2012). Twenty patients were
randomly allocated into two groups. After
tooth extraction, each socket was filled with
a cone that is comprised of b-tricalcium
phosphate (b-TCP) and type I collagen. The
sockets in the test group were covered with
collagen membranes, whereas the sockets in
the control group were not. Primary closure
was achieved in both groups by muco-perio-
153 | Clin. Oral Implants Res. 23, 2012 / 147–156
Wang & Lang
Ridge preservation revisited
steal flaps. Clinical assessments were per-
formed at baseline and at re-entry surgery
after 9 months of healing. No statistical sig-
nificant differences were found between the
test and control groups on horizontal ridge
resorption ( 0.86 mm vs. 1.29 mm, respec-
tively) or on vertical dimensional changes
(0.12 mm vs. 0.5 mm, respectively). Histo-
metric analysis showed that there was no dif-
ference between the test and control groups
regarding the amount of new bone (45.3% vs.
42.4%, respectively). Obviously, applying the
cone material with or without membranes
was effective in preserving the alveolar bone.
Primary flap closure
Primary closure versus no primary closure
Primary closure can also be attained by
means of an implant-supported provisional
prostheses, or using a customized healing
abutment. In a recent split-mouth clinical
trial (Engler-Hamm et al. 2011), molars or
premolars were extracted bilaterally in 11
patients. The sockets on both sides were
filled with an inorganic bovine-derived
hydroxyapatite matrix, cell-binding peptide
P-15 (ABM/P-15), DFDBA, and covered with
collagen membranes. Primary closure was
achieved on one side (control). On the other
side, the membranes were left uncovered
(test). Clinical assessments of the ridge width
were made using a caliper through a stent at
baseline and at after 6 month of healing. In
addition, questionnaires regarding the post-
operative discomfort were filled by the
patients. No significant differences were
found on the ridge width changes (3 mm vs.
3.42 mm). However, the post-operative dis-
comfort was significantly lower in the group
without primary closure. The mucogingival
junction was significantly more coronally
displaced in the group with primary closure.
Conclusions
Implants and associated techniques for alveolar
ridge preservation
• Implants placed into the fresh extraction
sockets do not prevent the resorption of
the alveolar bone. Although osseointegra-
tion is achieved in the early stage
(1 month in dogs), modeling of the bone
may cause this level to recede apically.
References
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154 | Clin. Oral Implants Res. 23, 2012 / 147–156
• Immediate loading of the implants in dogs
as well as in humans does not preserve the
alveolar bone ridge. The use of bone fillers
in residual defects around immediate
implants placed in well preserved, intact
alveoli in dogs may reduce soft tissue
recession as well as vertical and horizontal
resoprtion of the buccal bony plate.
• Simultaneous guided bone regeneration
procedures could partially resolve alveolar
bone resorption. However, this is
depended on the type of membrane as
well as the techniques applied.
• The use of root-formed implants, aiming
at closing the space between the implant
surface and alveolar bone of the extrac-
tion socket, does not preserve alveolar
bone ridges. On the contrary, their use
with this association was associated with
accentuated bone resorption.
• It was demonstrated that thicker bony
walls results in less resorption.
• The position of the implants was also an
essential factor for the alveolar bone ridge
preservation. Placing the immediate
implant 0.8mm deeper and more lingually
led to a reduction in the vertical buccal
bone resorption by 70% in dogs after
4 months of healing.
Non-surgical treatment
• There is not enough evidence to recom-
mend ultrasonic instrumentation for
alveolar ridge preservation and no conclu-
sions on its clinical benefits can be made.
Bone substitutes
• The only relevant dog study showed that
unfilled sockets underwent three times
the amount of horizontal resorption as
sockets filled with xenograft (Bio-oss®).
However, the xenograft only served as a
scaffold and did not stimulate new bone
formation.
• Various bone substitute materials have
been tested in clinical trials for their
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• Ridge preservation using human deminer-
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• Although DFDBA may be claimed to be
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• Although collagen plugs were claimed to
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Guided bone regeneration
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• A dog study revealed that using free gingi-
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ridge width. On the other hand, patients
experienced more discomfort with pri-
mary closed flaps. Moreover, the muco-
gingival junction was significantly more
coronally displaced in the primary closed
flap sites.
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was supported by a grant of the Clinical
Research Foundation (CRF) for the Promotion
of Oral Health, Brienz, Switzerland. The
senior author was an ITI Scholar 2010–2012
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Wah Lay Tan A systematic review of post-extrac-
Terry L. T. Wong
May C. M. Wong
tional alveolar hard and soft tissue
Niklaus P. Lang dimensional changes in humans

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

Corresponding author:
Background: Removal of teeth results in both horizontal and vertical changes of hard and soft
Prof. Niklaus P. Lang, DMD, MS, PhD, Dr odont.h. tissue dimensions. The magnitude of these changes is important for decision-making and
c. mult. comprehensive treatment planning, with provisions for possible solutions to expected
The University of Hong Kong Faculty of Dentistry
Prince Philip Dental Hospital complications during prosthetic rehabilitation.
34 Hospital Road, Sai Ying Pun Objectives: To review all English dental literature to assess the magnitude of dimensional changes
Hong Kong, China of both the hard and soft tissues of the alveolar ridge up to 12 months following tooth extraction
Tel.:+852 2859 0526
Fax: +852 2858 6114 in humans.
e-mail: nplang@dial.eunet.ch 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 and soft tissue dimensional changes after tooth extraction. Only studies reporting on undisturbed
The authors declare no conflict of interest. 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 11–22% at 6 months. Percentage horizontal dimensional change
was 32% at 3 months, and 29–63% at 6–7 months. Soft tissue changes demonstrated 0.4–0.5 mm
gain of thickness at 6 months on the buccal and lingual aspects. Horizontal dimensional changes of
hard and soft tissue (loss of 0.1–6.1 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 29–63% and vertical bone
loss of 11–22% after 6 months following tooth extraction. These studies demonstrated rapid
reductions in the first 3–6 months that was followed by gradual reductions in dimensions
thereafter.

The periodontium is an important structure tion or extraction of the tooth. Subsequent to

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, 1–21
doi: 10.1111/j.1600-0501.2011.02375.x
that supports the tooth and is affected by any
changes that the tooth may undergo, includ-
ing eruption and extraction (Cohn 1966; Pie-
trokovski & 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 pres-
ence or absence of teeth (Tallgren 1972). Sim-
ilarly, gingival tissues undergo changes
together with eruption and eventual exfolia-
removal of a tooth, the periodontium under-
goes 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, post-
extraction 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

© 2011 John Wiley & Sons A/S 1

Tan et al ! Dimensional tissue changes post extraction
and compositional changes in the overlying
soft tissue (Schropp et al. 2003). Both hori-
zontal 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 2–3 months post-
extraction, with the changes more pro-
nounced 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 over-
all 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 architec-
ture, but also affects the overlying soft tis-
sues 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 vol-
ume, and a soft tissue covering will seal the
socket entrance. The changes in the muco-
sal contours are dependent on the corre-
sponding changes in the external profile of
the alveolar bone surrounding the extraction
site.
The magnitude of these dimensional
changes are important for informed decision-
making and comprehensive treatment plan-
ning, 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 cou-
pled 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), 2012/1–21
that alveolar bone loss can be quite marked
after tooth removal (Araujo & Lindhe 2009),
especially in the horizontal dimension (Botti-
celli 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 system-
atic 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 extrac-
tion.
This study aims to review all existing liter-
ature published between 1st January 1960
and 30th January 2011, to assess the magni-
tude 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) state-
ment 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 MEDLINE–Pubmed data-
base and the Cochrane Central Register of
Controlled Trials (CENTRAL) was con-
ducted, 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 Janu-
ary 2011. The following key words were
used:
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>
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 Resorp-
tion 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 Muco-
sal Atrophy OR Mucosal Healing OR Gingi-
val 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 rele-
vant articles: Clinical Oral Implants
Research, International Journal of Oral &
Maxillofacial Implants, Implant Dentistry,
Journal of Periodontology, Journal of Clinical
Periodontology and Journal of Oral Implan-
tology.
Furthermore, the bibliographies of all pub-
lications 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 dimen-
sional soft tissue changes. Similarly, exclu-
sion 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 undis-
turbed 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 publica-
tions, the study with the most inclusive data
was preferentially selected.
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 MEDLINE–Pubmed database
and 1111 titles from the Cochrane Central
© 2011 John Wiley & Sons A/S
 Tan et al ! Dimensional tissue changes post extraction

Potentially relevant Register of Controlled Trials (CENTRAL).

Potentially relevant
publications identified from
publications identified from
electronic search of
electronic search of
Cochrane Central Register of
MEDLINE-Pubmed database
Controlled Trials (CENTRAL) st
st from 1 January 1960 to 30
database from 1 January
th
1960 to 30 June 2010
(n = 2843)
(n = 1111)
Potentially relevant full texts
retrieved for detailed
evaluation
(n = 104)
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)
Studies included in the
present systematic review
(n = 20)
Fig. 1. Search strategy. Post-extraction dimensional changes.
After careful independent screening of the
titles and elimination of duplicate titles by
th
both the examiners, a total of 238 titles were
June 2010
considered for possible inclusion. Retrieval of
the 238 abstracts and further perusal led to
104 full-text articles being selected. From
Publications excluded on the basis of title
and summary evaluation; also excluded these full-text articles, 19 were identified for
duplicate publications inclusion in the review.
(n = 3716)
Another article was deemed suitable from
the secondary electronic search, but no addi-
tional publications from the hand-search or
the bibliography search of the selected arti-
Publications excluded on the basis of full
text evaluation cles were identified for inclusion.
(n = 85) In total, 20 articles were identified for
eventual inclusion in this review (Fig. 1).
A j-score of 0.84 was obtained, for consen-
sus between the two reviewers.
Exclusion of studies
Publications included based on the hand- Of the 104 full-text articles examined, 85
search and bibliography search of
relevant articles were excluded from the final analysis
(n = 0)
(Table 1). The main reasons for exclusion
were that there were no actual measure-
Publications included based on the ments of the dimensional changes of the
secondary electronic search of the
MEDLINE-Pubmed and CENTRAL alveolar ridge, the reported parameters were
st st
database from 1 July 2010 to 31
January 2011
not useful for this review and that there was
(n = 1) 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 crite-
ria, 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; Reported parameters not relevant or not useful
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 Length of observation period not reported
Amemori 1966; Mizutani & Ishihata 1976; Olson & Hagen 1982; Hahn et al. 1988; Oltramari et al. Studies carried out on animals
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; Descriptive report on procedure/ technique;
Minsk 2005 commentary
Guglielmotti et al. 1986; Hsieh et al. 1995; Fickl et al. 2008c; Rothamel et al. 2008; Araujo & No baseline data available for comparison, thus unable
Lindhe 2009a; Pessoa et al. 2009 to arrive at an estimate of dimensional change over
time
Carlsson & Persson 1967; Pietrokovski & Massler 1967b; Pietrokovski 1967; Green et al. 1969; No measurements of alveolar dimensional changes (e.g.
Huebsch & Hansen 1969; Berkovitz 1971; Pietrokovski & Massler 1971; Hars & Massler 1972; description of healing process or bony shape change,
Librus et al. 1973; Thilander & Astrand 1973; Horn et al. 1979; Olson et al. 1982; Quinn & or histology only)
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. Study subjects had immediate dentures after extraction,
1988 hence they did not have undisturbed healing
post-extraction
Bahat et al. 1987; Iizuka et al. 1992; Yugoshi et al. 2002; Araujo et al. 2005; Lindeboom et al. Sample did not include untreated/undisturbed extraction
2006; Wu et al. 2008; Araujo & Lindhe 2009b; Nevins et al. 2009 sockets left to heal spontaneously
Araujo & Lindhe 2005 Only measured relative difference in height between
buccal and lingual plates of the alveolus

© 2011 John Wiley & Sons A/S 3 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Tan et al ! Dimensional tissue changes post extraction
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
Collaboration’s tool for assessing risk of bias
was used in the case of randomized con-
trolled 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 publi-
cations 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 con-
duct 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 measure-
ment methods and reference points, we pre-
sented 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:
1
Wi ¼
ri2
The weighted mean in this case is:
Pn
ðxi =r2i Þ
x! ¼ Pi¼1
n 2
i¼1 ð1=ri Þ
and the variance of the weighted mean is:
1 2009; Moya-Villaescusa & Sanchez-Pérez
r2x! ¼ Pn 2
i¼1 ð1=ri Þ
4 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
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 Cochran’s Q-test:
X
Q¼ wi ðxi % x!Þ
The P-value was then calculated for the Q
statistic and a value of P < 0.05 would indi-
cate significant statistical heterogeneity
between the studies.
When Q > df, where df is its degree of free-
dom, the I2 index was also calculated using
the following formula:
! "
Q % df
I2 ¼ & 100%
Q chlorhexidine mouthrinse on post-extraction
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 consider-
able 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 signifi-
cant.
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 clini-
cal 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, car-
ies, 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.
2010; Rasperini et al. 2010) reported on data
including molar extraction sites and one
study (Oghli & Steveling 2010) did not spec-
ify where the extractions were performed.
Most of the data extracted concerned teeth in
control groups of studies that evaluated vari-
ous ridge preservation procedures (Lekovic
et al. 1997, 1998; Yilmaz et al. 1998; Camar-
go 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 post-
extraction alveolar changes (Carlsson & Pers-
son 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
healing. Each paper that was included in
this review contributed a number of extrac-
tion 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 sponta-
neous 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 indepen-
dently or in combination by 17 studies
(Tables 4 and 7).
Vertical linear hard tissue alteration
All 17 studies that reported on post-extrac-
tion hard tissue changes looked into the ver-
tical 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.
© 2011 John Wiley & Sons A/S
 Tan et al ! Dimensional tissue changes post extraction

Table 2. Cochrane Collaboration’s tool for assessing risk of bias

Carlsson & Persson (1967) Brägger et al. (1994)
Controlled clinical trial Randomized controlled clinical trial
Study design Parallel Parallel
Adequate sequence generation No Unclear
Remark Quote “alternate patients were assigned to respective Quote “then randomly assigned”
groups”
Insufficient information about sequence generation
Allocation concealment Unclear Unclear
Remark No information provided. No information provided.
Blinding Unclear Yes
Remark Study did not address this outcome. Quote “ double-blind clinical trial”
Incomplete outcome data addressed Yes No
Remark Quote “one patient from each group had to be Initially mentioned that 40 patients were enrolled in
discarded….one had moved…other case first radiograph study, but subsequently only obtained radiographs for
unsuccessful and could not be repeated..” 23 patients with no explanation
Free of selective reporting Yes No
Remark Initially mentioned that 40 patients were enrolled in
study, but subsequently only obtained radiographs for
23 patients with no explanation
Free of other sources of bias Yes Yes
Remark
Overall risk of bias High High

Lekovic et al. (1997) Lekovic et al. (1998)

Controlled clinical trial Randomized controlled clinical trial
Study design Split-mouth Split-mouth
Adequate sequence generation Unclear Yes
Remark No information provided Quote “ control and experimental sites were assigned by
the flip of a coin”
Allocation concealment Unclear Unclear
Remark No information provided No information provided
Blinding Unclear Yes
Remark Study did not address this outcome Quote “clinical measurements were performed by one
clinician who did not have knowledge of control and
experimental sites”
Incomplete outcome data addressed Yes Yes
Remark Mentioned that three patient had dehiscence in test No missing outcome data
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 3–5 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
Free of selective reporting Yes Yes
Remark
Free of other sources of bias Yes Yes
Remark
Overall risk of bias Unclear Unclear

Camargo et al. (2000) Iasella et al. (2003) Serino et al. (2003) Fiorellini et al. (2005)
Randomized controlled Randomized controlled clinical
Controlled clinical trial clinical trial Controlled clinical trial trial
Study design Split-mouth Parallel Parallel and split-mouth Parallel
Adequate sequence Unclear Yes Unclear Unclear
generation
Remark No information provided Quote “randomly selected No information provided Quote “ cohorts of 40 patient
using a coin toss” randomized in a double-blind
manner”
Insufficient information about
sequence generation
Allocation Unclear Unclear Unclear Unclear
concealment
Remark No information provided No information provided No information provided No information provided
Blinding Unclear Yes Unclear Yes
Remark Study did not address this Quote “measurements were No information provided Quote “all the patients in the study
outcome taken by 2 masked underwent the same surgical
examiners” procedure, regardless of the
treatment
Incomplete outcome Yes Yes Yes Yes
data addressed

© 2011 John Wiley & Sons A/S 5 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Tan et al ! Dimensional tissue changes post extraction

Table 2. (continued)
Camargo et al. (2000) Iasella et al. (2003) Serino et al. (2003) Fiorellini et al. (2005)
Randomized controlled Randomized controlled clinical
Controlled clinical trial clinical trial Controlled clinical trial trial
Study design Split-mouth Parallel Parallel and split-mouth Parallel
Remark No missing outcome data Quote “implants were Quote “nine subjects Quote “ No subjects were
successfully placed at all dropped out from the withdrawn or lost to follow-up”
sites….none have been study for reasons unrelated
subsequently lost” to the therapy”
Free of selective Yes Yes Yes Yes
reporting
Remark
Free of other sources Yes Yes Yes Yes
of bias
Remark
Overall risk of bias Unclear Unclear Unclear Unclear

Barone et al. (2008) Kerr et al. (2008) Aimetti et al. (2009)

Randomized controlled clinical
Randomized controlled clinical trial Randomized controlled clinical trial trial
Study design Parallel Split-mouth Parallel
Adequate sequence generation Yes Unclear Unclear
Remark Quote “using a Quote “ one site was assigned Quote “ were consecutively
computer-generated randomly as test, whereas the selected..” and “ all sockets were
randomisation list…” other site was assigned as control” measured and assigned randomly
to test or control”
Insufficient information about Insufficient information about
sequence generation sequence generation
Allocation concealment Unclear Unclear No
Remark No information provided No information provided Assignment not explicitly
concealed
Blinding Yes Yes Yes
Remark Quote “all measurements were Quote “examiner was masked as to Quote “recorded by the same
taken by one examiner who was whether sites were test or control” examiner, who was not involved
not involved in performing the in providing therapy”
surgical treatment…”
Incomplete outcome data addressed Yes Yes Unclear
Remark No loss to follow-up in test and No missing outcome data Study did not address this
control group outcome
Free of selective reporting Yes Yes Yes
Remark
Free of other sources of bias Yes Yes Yes
Remark
Overall risk of bias Unclear Unclear High

Crespi et al. (2009) Pelegrine et al. (2010) Rasperini et al. (2010)

Randomized controlled clinical
Controlled clinical trial Randomized controlled clinical trial trial
Study design Split-mouth Parallel Parallel
Adequate sequence generation No Unclear Yes
Remark Quote “sockets on right side of jaw Quote “teeth to be extracted were Quote “treatment regimens were
received MHA….sockets on left randomized into two groups” assigned randomly to the subjects
side received CS…” with a balanced random permuted
block approach”
Allocation by left or right side Insufficient information about
of jaw sequence generation
Allocation concealment Unclear Unclear Yes
Remark No information provided. No information provided. Quote “treatment regimens
assigned randomly…
communicated to the operator
immediately after tooth
extraction”
Blinding Yes Unclear Yes
Remark Quote “a masked examiner Study did not address this outcome Quote “tubes included into the
measured the bone level changes.” stent by a blind examiner…..after
surgery, blinded examiner
positioned the stent.”
Incomplete outcome data addressed Yes Unclear Yes
Remark No missing outcome data Study did not address this outcome. Missing outcome data balanced in
numbers across groups
Free of selective reporting Yes Yes Yes
Remark
Free of other sources of bias Yes Yes Yes
Remark
Overall risk of bias High Unclear Low

6 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21 © 2011 John Wiley & Sons A/S
 Tan et al ! Dimensional tissue changes post extraction

Table 2. (continued)
Yilmaz et al. (1998) Oghli & Steveling (2010)
Controlled clinical trial Randomized controlled clinical trial
Study design Parallel Parallel
Adequate sequence generation Unclear Unclear
Remark No information provided Quote “patients were divided randomly into three groups”
Insufficient information about sequence generation
Allocation concealment Unclear Unclear
Remark No information provided No information provided
Blinding Unclear Unclear
Remark Study did not address this outcome Study did not address this outcome
Incomplete outcome data addressed Unclear Yes
Remark Study did not address this outcome All exclusions accounted for
Free of selective reporting Yes Yes
Remark
Free of other sources of bias Yes Yes
Remark
Overall risk of bias Unclear Unclear

2008; Crespi et al. 2009; Moya-Villaescusa &
Sanchez-Pérez 2010) utilized imaging meth-
ods 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 ver-
tical linear hard tissue changes of the alveolus;
four studies (Lekovic et al. 1997, 1998; Camar-
go et al. 2000; Pelegrine et al. 2010) utilized a
titanium screw or pin, while two studies (Ia-
sella 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 respec-
tively. Later, Pelegrine et al. (2010) showed
that 6 months after extraction of maxillary
anterior teeth, the mean buccal vertical alve-
olar ridge height reduction was
1.17 ± 0.26 mm. All the four studies men-
tioned 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-
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,
1998; Camargo et al. 2000; Iasella et al. 2003;
Serino et al. 2003; Pelegrine et al. 2010), the
weighted mean was calculated for the rele-
vant 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-lin-
gual, mesial and distal sites respectively, at re-
entry. A stent was used as a fixed reference.
Rasperini et al. (2010) reported on 3- and 6-
month dimensional changes of the alveolar
ridge after extraction of maxillary molar
teeth, using a custom acrylic stent and a peri-
odontal 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 radiogra-
phy 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 (Salda-
nha et al. 2006), and intraoral peri-apical radi-
ography in four studies (Bragger et al. 1994;
Schropp et al. 2003; Crespi et al. 2009 and
Moya-Villaescusa & Sanchez-Pérez 2010).
Carlsson & Persson (1967) attempted to
use lateral cephalometric radiography to dem-
onstrate 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 tis-
sues in this case.
Two studies (Fiorellini et al. 2005; Kerr
et al. 2008) utilized computed tomography to
detect vertical height changes in the alveolar

© 2011 John Wiley & Sons A/S 7 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Tan et al ! Dimensional tissue changes post extraction

Table 3. Newcastle–Ottawa Quality Assessment Scale for Cohort Studies (max 9*)
Schropp et al. (2003) Saldanha et al. (2006)
Study design Cohort Cohort
Selection
Representativeness of the exposed Truly representative of the average implant Representative of the average patient
cohort patient in the community requiring extraction in the community
Rating * *
Selection of non exposed cohort No description of the derivation of non-exposed No description of the derivation of the non-exposed
cohort cohort
Rating
Ascertainment of exposure Secure record (radiograph, study model, clinical Secure record (radiograph, linear tomography, clinical
exam) exam)
Rating * *
Demonstration that outcome of Yes Yes
interest was not present at
start of study
Rating * *
Comparability
Comparability of cohorts on the No mention of control of any confounding factors (e.g. Controlled for confounding factors (smoking, oral
basis of the design or analysis smoking, health) hygiene, ethnicity, systemic health)
Rating **
Outcome
Assessment of outcome Records (radiograph, study models) Independent blind assessment
Rating * *
Was follow-up long enough for Yes; 12 months follow up (early soft/hard tissue healing Yes; 6 months (early hard tissue healing usually
outcomes to occur usually 6–8 weeks) 6–8 weeks)
Rating * *
Adequacy of follow up of cohorts Description of those lost to follow-up No statement
Rating *
Overall 6* 7*

Rodd et al. (2007) Moya-Villaescusa & Sanchez-Pérez (2010)

Study design Cohort Cohort
Selection
Representativeness of the exposed Truly representative of the average young patient Representative of the average patient requiring
cohort with dental trauma in the community extraction in the community
Rating * *
Selection of non exposed cohort No description of the derivation of non-exposed No description of the derivation of non-exposed
cohort cohort
Rating
Ascertainment of exposure Secure record (study model, photograph, clinical Secure record (radiograph, clinical exam)
exam)
Rating * *
Demonstration that outcome of interest Yes Yes
was not present at start of study
Rating * *
Comparability
Comparability of cohorts on the basis Sample size too small to allow statistical Controlled for confounding factors (smoking, number
of the design or analysis adjustment of confounders of roots, oral hygiene, periodontal disease)
Rating **
Outcome
Assessment of outcome Records (study model, photograph) Records (radiograph)
Rating * *
Was follow-up long enough for Yes; 4–61 months follow up (early soft/hard tissue Yes; 3 months follow up (early hard tissue healing
outcomes to occur healing usually 6–8 weeks) usually 6–8 weeks)
Rating * *
Adequacy of follow up of cohorts No statement No statement
Rating
Overall 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
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 ante-
rior 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

8 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21 © 2011 John Wiley & Sons A/S
 Tan et al ! Dimensional tissue changes post extraction

Table 4. Characteristics of studies included for hard tissue change only

No. of
Author, Sample extraction
Title publishing year Species QA Tissue Methods size sites
Morphologic changes of the mandible after extraction Carlsson 1967 human CCT Hard Radio 17 5–6 per pt
and wearing of denture
Effect of chlorhexidine(0.12%) rinses on periodontal Bragger 1994 Human RCCT Hard Radio 12 21
tissue healing after tooth extraction(II)radiographic
parameters
A bone regeneration approach to alveolar ridge Lekovic 1997 Human CCT Hard Re-entry (pin) 10 10
maintenance following tooth extraction. Report of
10 cases
Preservation of alveolar bone in extraction sockets Lekovic 1998 Human RCCT Hard Re-entry 16 16
using bioabsorbable membranes (pin 2–5 mm)
Influence of bioactive glass on changes in alveolar Camargo 2000 Human CCT Hard Re-entry 16 16
process dimensions after exodontia (pin 1–8 mm)
Ridge preservation with freeze-dried bone allograft Iasella 2003 Human RCCT Soft Re-entry 12 12
and a collagen membrane compared to extraction + hard (stent)
alone for implant site development: a clinical and
histological study in humans
Ridge preservation following tooth extraction using Serino 2003 Human CCT Hard Re-entry 12 13
a polylactide and polyglycolide sponge as space filler: (stent)
a clinical and histological study in humans
Bone healing and soft tissue contour changes Schropp 2003 Human Cohort Hard Radio 46 46
following single-tooth extraction: a clinical and
radiographic 12-month prospective study
Randomized study evaluating recombinant human Fiorellini 2005 Human RCCT Hard CT scan 20 ?
bone morphogenetic protein-2 for extraction socket
augmentation
Smoking may affect the alveolar process dimensions Saldanha 2006 Human Cohort Hard Radio 21 21
and radiographic bone density in maxillary extraction
sites: a prospective study in humans
Xenograft vs. extraction alone for ridge preservation Barone 2008 Human RCCT Hard Re-entry 20 20
after tooth removal: a clinical and histomorphometric (stent)
study
The effect of ultrasound on bone dimension changes Kerr 2008 Human RCCT Hard CBVT (ref 12 12
following extraction: a pilot study plate)
Clinical and histological healing of human extraction Aimettl 2009 Human RCCT Hard Re-entry 18 18
sockets filled with calcium sulphate (stent)
Magnesium-enriched hydroxyapatite compared to Crespi 2009 Human RCCT Hard Radio 15 15
calcium sulphate in the healing of human extraction
sockets: radiographic and histomorphometric
evaluation at 3 months
Measurement of ridge alterations following tooth Moya-Villaescusa Human Cohort Hard Radio 100 100
removal:a radiographic study in humans 2010
Clinical and histomorphometric evaluation of Pelegrine 2010 Human RCCT Hard Re-entry (pin) 6 15
extraction sockets treated with an autologous bone
marrow graft
Socket grafting in the posterior maxilla reduces the Rasperini 2010 Human RCCT Hard Stent 3 3
need for sinus augmentation

loss of 3.75 ± 0.63 mm when the buccal plate
was lost during extraction. One study (Moya-
Villaescusa & Sanchez-Pérez 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 differ-
ence 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
percentage reduction of the vertical dimen-
sion of the alveolus post-extraction as fol-
lows:
%vertical linear change ðhard tissueÞ
vertical linear resortion ðhard tissueÞ
¼
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,
1998; Camargo et al. 2000; Iasella et al. 2003;
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 tis-
sue 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) docu-
mented 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

© 2011 John Wiley & Sons A/S 9 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Tan et al ! Dimensional tissue changes post extraction

Fig. 5. Horizontal (linear) hard tissue change for re-

entry studies only.

Fig. 2. Vertical (linear) hard tissue change for re-entry

studies only.

Fig. 3. Vertical (linear) hard tissue change for re-entry

Fig. 6. Horizontal (linear) hard tissue change for re-
studies (Q = 17.8, P < 0.05; I2 = 77.6%, studies only; weighted means shown.
entry studies only; weighted means shown.
P < 0.05). In this case, although the weighted
mean was calculated by applying the inverse
variance method to arrive at a value of
The calculated percentage horizontal
3.79 ± 0.23 mm horizontal reduction at
change of the alveolar hard tissue at the alve-
6 months (Fig. 6) across all five studies, the
olar crest ranged from 32% at 3 months, and
robustness and applicability of this value
between 29% and 63% after 6–7 months
should be questioned.
post-extraction (Fig. 8).
Saldanha et al. (2006) reported the horizon-
tal reduction of the alveolar bone at 0% and
Overall hard tissue changes
50% the distance from the crest. This study
In general, with regard to vertical dimen-
demonstrated a 6-month reduction of 0.6 and
sional change, we can see a trend where
1.3 mm for non-smokers and smokers respec-
there is a greater reduction on the buccal and
tively at 0% from the alveolar crest and cor-
lingual sites as compared to the mesial and
responding values of 0.1 and 0.8 mm at 50%
distal sites. Looking at the horizontal dimen-
from the crest. This study utilized linear
sional change, there is a distinct pattern of
tomography to track the changes. Fig. 4. Vertical (linear) hard tissue percentage change in resorption where the resorption decreases
Of note, Kerr et al. (2008) demonstrated four studies.
with increased distance from the alveolar
beautifully that 3 months after tooth extrac-
baseline ridge width immediately post-extrac- crest. Overall, the observed horizontal resorp-
tion, there was a relative decrease in horizon-
tion. This facilitated a calculation of the per- tion of the hard tissues (29–63%) is far
tal ridge reduction as the distance from the
centage reduction of the horizontal dimension greater than the resorption in the vertical
alveolar crest increased (Fig. 7).
of the alveolus post-extraction as follows: dimension (11–22%), over an observation per-
iod of 3–7 months. It can be seen that the
Percentage change of horizontal linear hard tissue
alteration %horizontallinear changeðhard tissueÞ bulk of the resorption occurs in the first
All but one study (Kerr et al. 2008) reporting horizontal linear resortionðhard tissueÞ 3 months post-extraction, and the changes
¼
changes in the ridge width also reported the baseline internal socket height are much more subtle thereafter.

10 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21 © 2011 John Wiley & Sons A/S
 Tan et al ! Dimensional tissue changes post extraction

Fig. 9. Change in soft tissue dimensions over time.

pendently or in combination; in one study

(Rodd et al. 2007) the overall areal change of
Fig. 8. Horizontal (linear) hard tissue percentage the alveolar hard and soft tissue combined,
change. was reported.

Vertical linear combined hard and soft tissue

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 tis-
sue dimensions in the alveolus post-extrac-
tion (Tables 5 and 7). This study
demonstrated a 0.4–0.5 mm gain of soft tis-
sue thickness at 6 months, measured at buc-
cal and lingual sites 3 mm from the alveolar
crest. Occlusally, soft tissue with thickness
of 2.1 mm developed after 6 months to com-
plete soft tissue coverage of the wound
(Fig. 9).
Combined hard and soft tissue changes
To date, a total of five studies (Carlsson &
Persson 1967; Yilmaz et al. 1998; Schropp
et al. 2003; Rodd et al. 2007; Oghli & Stevel-
ing 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 & Pers-
son 1967) utilized lateral cephalometric radi-
ography 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-
alteration
Three studies (Carlsson & Persson 1967; Yil-
maz et al. 1998 and Schropp et al. 2003)
addressed the combined hard and soft tissue
changes in the vertical dimension of the alve-
olus.
With the aid of lateral cephalometric radi-
ography, 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 verti-
cal 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 reduc-
tion of 0.1 ± 0.52 mm and 0.5 ± 0.76 mm at

Table 5. Characteristic of study included for soft tissue change only

Author, No. of
Title Publishing Year Species QA Tissue Methods Sample size extraction site
Ridge preservation with freeze-dried bone allograft Iasella 2003 Human RCCT Soft + hard Re-entry (stent) 12 12
and a collagen membrane compared to extraction
alone for implant site development: a clinical and
histological study in humans

Table 6. Characteristics of studies included for both hard and soft tissue changes combined
No. of
Title Authors Species QA Tissue Method Sample size extraction sites
Morphologic changes of the mandible after extraction Carlsson 1967 Human CCT Soft + hard Radio 17 5/6 per pt
and wearing of denture
Alveolar ridge reconstruction and/or preservation Yilmaz 1998 Human CCT Soft + hard Cast 5 10
using root form bioglass cones
Bone healing and soft tissue contour changes Schropp 2003 Human CCT Soft + hard Cast 46 46
following single-tooth extraction: A clinical and
radiographic 12-month prospective study
Change in supporting tissue following loss of a Rodd 2007 Human Cohort Soft + hard Cast 16 16
permanent maxillary incisor in children
Ridge preservation following tooth extraction: Oghli 2010 Human RCCT Soft + hard Cast 72 101
A comparison between atraumatic extraction and
socket seal surgery

© 2011 John Wiley & Sons A/S 11 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Tan et al ! Dimensional tissue changes post extraction

Table 7. Overall results from all studies

No. of
Author, Sample extraction Vertical dimensional Horizontal dimensional
Publishing Year Species Tissue Methods size sites change change
Carlsson 1967 Human Hard Radio 17 5–6 per pt 2 month: %2.0(0.9) 2 month: %2.2(1.1)
4 month: %2.9(1.7) 12 month: %3.6(0.5)
6 month: %3.4(2.1) 60 month: %4.0(1.5)
12 month: %4.1(2.7)
24 month: %4.9(3.7)
60 month: %7.3(3.7)
Bragger 1994 Human Hard Radio 12 21 1 month: %0.61(0.67)
2 month: %0.67(0.66)
3 month: %1.19(1.50)
6 month: %0.93(0.74)
Lekovic 1997 Human Hard Re-entry (pin) 10 10 6 month: %1.2(0.13) 6 month: %4.4(0.61)
Lekovic 1998 Human Hard Re-entry (pin2– 16 16 6 month: %1.50(0.26) 6 month: %4.56(0.33)
5 mm)
Camargo 2000 Human Hard Re-entry (pin1– 16 16 6 month: %1.00(2.25) 6 month: %3.06(2.41)
8 mm)
Iasella 2003 Human Soft+ Re-entry (stent) 12 12 6 month: B %0.9(1.6) 6 month: %2.6(2.3)
hard L %0.4(1.0)
M %1.0(0.8)
D %0.8(0.8)
Iasella 2003 Human Soft Re-entry (stent) 12 12 6 month: B 0.4(0.6)
L 0.5(1.5)
(Soft tissue thickness change)
Serino 2003 Human Hard Re-entry (stent) 12 13 6 month: B %0.8(1.6)
M %0.6(1.0)
D %0.8(1.5)
Schropp 2003 Human Hard Radio 46 46 12 month: M %0.3
D %0.3
Schropp 2003 Human Soft+ Cast 46 46 3 month: B %0.1 3 month: %3.8
hard 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
Fiorellini 2005 Human Hard CT scan 20 ? 4 month: %1.17(1.23)
Saldanha 2006 Human Hard Radio 21 21 6 month: %1.0 to 1.5 6 month: %0.1 to 1.3
Barone 2008 Human Hard Re-entry (stent) 20 20 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)
Kerr 2008 Human Hard CBVT 12 12 1 month:B %1.01(0.39) 1 month: %0.16(0.96)
(ref plate) 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)
Aimettl 2009 Human Hard Re-entry (stent) 18 18 3 month: B%1.2(0.6)
L %0.9(1.1)
M %0.5(0.9)
D %0.5(1.1)
Crespi 2009 Human Hard Radio 15 15 3 month: %3.75(0.63)
Moya-Villaescusa Human Hard Radio 100 100 3 month: %4.32(0.23)
2010
Pelegrine 2010 Human Hard Re-entry (pin) 6 15 6 month: %1.17(0.26)
Rasperini 2010 Human Hard Stent 3 3 3 month: %2.2
6 month: %5.7(4.2)
Yilmaz 1998 Human Hard Cast 5 10 3 month: %0.1(0.52) 3 month: %0.1(0.23)
12 month: %0.5(0.76) 12 month: %0.4(0.48)
Rodd 2007 Human Hard Cast 16 16 3 month: 15.7%
6 month: 25.3%
9 month: 22%
(Bone surface area)
Oghli 2010 Human Hard Cast 72 101 3 month: %0.3(0.5)

3 and 12 months respectively, post-extrac- well as 3, 6 and 12 months after extraction was followed by a net gain of 0.1 mm at
tion of maxillary incisor teeth (Fig. 10). of maxillary posterior teeth. Taking the 6 months and 0.4 mm at 12 months of the
Schropp et al. (2003) took measurements occlusal surfaces of adjacent teeth as refer- buccal sites. Lingual sites demonstrated a
from study casts taken immediately after as ence, a reduction of 0.1 mm at 3 months loss of 0.8–0.9 mm between 3 and 6 months,

12 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21 © 2011 John Wiley & Sons A/S

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; Yil-
maz et al. 1998; Schropp et al. 2003; Oghli &
Steveling 2010) presented data on the com-
bined hard and soft tissue change in the hori-
zontal dimension following extraction.
The only study using radiographic methods
(Carlsson & Persson 1967) demonstrated a
reduction of the alveolar width in the magni-
tude of 2.2 mm at 2 months, which subse-
quently 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 stud-
ies (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 12-
month reduction in width of 0.1 ± 0.23 mm
and 0.4 ± 0.48 mm respectively, while Oghli
& Steveling (2010) reported a 3-month reduc-
tion 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
© 2011 John Wiley & Sons A/S
Tan et al ! Dimensional tissue changes post extraction
always more substantial than the vertical
change.
Discussion
The 20 included studies in this systematic
review were of different study designs and
measured dimensional change in various
ways.
Eleven randomized controlled clinical tri-
als, five controlled clinical trials and four
cohort studies were included in this review.
Fig. 11. Horizontal (linear) change of hard and soft tis- It is common knowledge that randomized
sues combined.
controlled clinical trials and the systematic
review of randomized controlled clinical tri-
als provide the highest level of evidence
provide any information on the standard related to intervention and therapy. However,
deviations in the study, so it was impossible in the case of post-extractional dimensional
to utilize the inverse variance method to cal- changes of the alveolar hard and soft tissues,
culate the weighted means. there are no randomized controlled clinical
trials where the control procedure is where
Cross-sectional surface area alteration of combined the tooth was left in situ and the test proce-
alveolar hard and soft tissues
dure was extraction. Hence, the cohort stud-
A single study reported on change in alveolar
ies where post-extraction alveolar hard and
surface area of the hard and soft tissues com-
soft tissues changes were monitored longitu-
bined (Rodd et al. 2007); measurements were
dinally might provide better insight and be
obtained from study casts acquired prior to,
the more appropriate study design.
and at 3, 6 and 9 months following extrac-
The three main measuring methods uti-
tion of maxillary central incisors in children.
lized were: (i) re-entry (ii) imaging and (iii)
The reductions in surface area were presented
study models. The re-entry method consti-
as a percentage of the surface area on the pre-
tuted of elevating a flap during extraction
extraction cast, and were as follows: 15.7%
and again at re-evaluation. All the studies
at 3 months, 25.3% at 6 months and 22% at
using the re-entry method measured the
9 months.
parameters from a fixed reference, namely an
acrylic stent or a titanium pin or screw. The
Overall combined hard and soft tissue changes
imaging method included the utilization of
With the aid of various assessment methods,
periapical radiographs, lateral cephalometric
a longitudinal change of the combined hard
radiography, or computer tomography. The
and soft tissues in the vertical dimension
method where study models were utilized
was found to be anywhere between a loss of
required that study impressions be taken
4.0 mm to a gain of 0.4 mm over a period of
before, or immediately after extraction, and
2–12 months.
again at re-evaluation.
Study casts and radiographs were employed
Re-entry studies evaluated hard tissue as
to assess the reduction of the combined hard
well as soft tissues as separate entities, while
and soft tissues in the horizontal dimension.
imaging studies evaluated either hard tissue
This reduction was demonstrated to be
dimension only, or the combined hard and
between 0.1 and 6.1 mm when the observa-
soft tissue changes. Study model studies
tion periods varied from 3 to 12 months, and
focused on combined hard and soft tissue
the measurements were taken at the alveolar
dimensional changes. During data analysis
crest. When the measurements were taken
process, we subdivided the data into different
3 mm apical to the alveolar crest, the corre-
groups, mainly according to measurement
sponding horizontal reductions of the com-
methods and the tissues involved. The
bined hard and soft tissues were 2.2 mm at
groups include (i) hard tissue group, (ii) soft
2 months and 3.6 mm at 12 months. Reduc-
tissue group, and (iii) combined hard and soft
tions in cross-sectional surface area of the tis-
tissue group.
sues were up to 22% after 9 months.
Mimicking the changes of the alveolar hard
Heterogeneity assessment
tissue, there is a similar pattern of resorption
The 20 included studies had different obser-
when we look at the combined hard and
vation time points, methodologies, and
soft tissue entity; the horizontal alteration is
13 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Tan et al ! Dimensional tissue changes post extraction
measurement methods. Heterogeneity assess-
ment 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 differ-
ences in sample sizes, different behaviours of
study populations, varied observation time
points and measurement parameters contrib-
uted to the heterogeneity. Although weighted
means were calculated, the resultant values
should really only be used for reference pur-
poses. 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 buc-
cal, lingual, mesial and distal bone plates.
Two of the three studies, namely Barone
et al. (2008) and Aimetti et al. (2009), demon-
strated that buccal/lingual sites (0.9–3.6 mm
loss at 3–7 months) had more resorption than
mesial/distal sites (0.4–0.5 mm loss at 3–
7 months). Referring to the calculated values
of the respective weighted mean, buccal bone
plates (1.24 mm loss at 3–7 months) also had
a tendency to resorb more than mesial/distal
bone sites (0.8–0.84 mm at 3–7 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 lin-
gual bone plates. All three studies showed
that the buccal plate resorption (0.9–3.6 mm
at 3–7 months) was of greater magnitude
than that of the lingual plate (0.4–3 mm at 3
–7 months). This finding was similar to pre-
vious studies in the canine model (Araujo &
Lindhe 2005; Araujo et al. 2005). This pattern
14 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
of resorption can be explained by the bundle
bone concept as proposed by Araujo & Lind-
he (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 differ-
ence 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 0.3–0.6 mm over a period of 3 and
7 months, in our review. One possible expla-
nation 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).
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 3–7 months.
Hard tissue vertical dimensional percentage
change
Lekovic et al. (1997, 1998), Camargo et al.
(2000), Pelegrine et al. (2010) reported base-
line data of the internal socket height imme-
diately post-extraction. Internal socket height
is a measurement from buccal bone crest to
the bottom of the extraction socket. The pro-
vision 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 buc-
cal 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 11–22%, as the amount of
resorption in these areas have been shown to
be of a comparatively lesser magnitude. Cor-
respondingly, from this this percentage, we
can interpret that there might be 78–89%
bone fill of the original socket height, calcu-
lated as percentage vertical bone fill equals
one minus vertical dimensional percentage
change.
Hard tissue horizontal dimensional change
Five re-entry studies (Lekovic et al. 1997,
1998; Camargo et al. 2000; Iasella et al. 2003;
Pelegrine et al. 2010) showed that there was
range of 2.46–4.56 mm horizontal bone loss
and weighted mean resorption of 3.79 mm at
6 months. However, theses studies only pro-
vided data for horizontal resorption at the
level of the alveolar crest, no data was avail-
able 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 find-
ing was similar to a dog study done by Ara-
ujo & Lindhe (2009), which observed more
resorption at coronal third and least resorp-
tion at apical third of the alveolar ridge.
Hence, it is expected that the amount of hor-
izontal 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.
Hard tissue horizontal dimensional percentage
change
There was 32% reduction at 3 months, and
29–63% reduction in horizontal dimension
at 6 months. This demonstrated that possi-
bly 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 pala-
tal 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 val-
ues and percentage change. Horizontal reduc-
tion (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 11–22% at 6 months while per-
centage horizontal change was 32% at
3 months, and 29–63% 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–
© 2011 John Wiley & Sons A/S

0.5 mm gain in soft tissue thickness on buc-
cal and lingual sites at 6 months. Interest-
ingly, from this study, a difference was found
in the change of soft tissue thickness over a
natural healing socket, and sockets aug-
mented 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 possi-
ble 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 meth-
ods 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 maxil-
lary 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 Sch-
ropp 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 ran-
ged 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 tis-
sue changes. The studies by Yilmaz et al.
(1998) and Schropp et al. (2003) had a follow-
up of up to 12 months; both studies exhib-
© 2011 John Wiley & Sons A/S
Tan et al ! Dimensional tissue changes post extraction
ited a trend where there was a rapid reduc-
tion 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 hori-
zontal reduction of 0.1–3.8 mm and 5.1 mm
at 3 and 6 months respectively. Correspond-
ingly, 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 demon-
strated horizontal change was more substan-
tial 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 reduc-
tion than hard tissue only; this observation is
not corroborated in the vertical aspect.
In the vertical dimension, when consider-
ing 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 0.4–0.5 mm on buccal/lin-
gual) 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 dif-
ference 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
15 |
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 extrac-
tion socket affected the overall dimensional
change of ridge. The vertical alveolar ridge
height in this study decreased slightly ini-
tially, 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 extrac-
tion. Saldanha et al. (2006) showed that
there was a significant difference in dimen-
sional reduction between smoking and non-
smoking groups. There was vertical alveolar
ridge reduction of 1.5 mm in smokers and
1.0 mm in non-smokers, 6 months post-
extraction.
Single-rooted vs. multiple-rooted teeth
Moya-Villaescusa & Sanchez-Pérez (2010)
study showed there was no significant differ-
ence 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,
Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Tan et al ! Dimensional tissue changes post extraction
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 con-
tinue throughout life once the teeth are
extracted. Take note, however, that all the
patients in this study wore complete den-
tures; dentures were inserted 2 months after
extractions in the conventional group and
immediately after extractions in the immedi-
ate group. We can speculate that the usage of
removable complete dentures may also affect
the pattern of resorption of the alveolar tis-
sues.
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16 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Conclusions
In conclusion, the studies included in this
review demonstrated that horizontal bone
loss (29–63%, 2.46–4.56 mm, weighted mean
3.79 mm at 6 months) was more substantial
than vertical bone loss (11–22%, 0.8–1.5 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 resorp-
tion pattern of rapid reduction in the first 3–
6 months, followed by gradual reduction
thereafter, throughout life.
Soft tissue on the buccal and lingual sur-
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reported in one study; the significance of this
finding is as yet unknown. The same study
also documented that 6 months post-extrac-
tion, a soft tissue cover of 2.1 mm in thick-
ness developed over the original socket; this
soft tissue thickness that develops post-
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tissue resorption and impact on the overall
outcome of any reconstructive efforts, espe-
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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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© 2011 John Wiley & Sons A/S

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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.
The International Journal of Oral & Maxillofa-
cial Implants 24: 902–929.
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 histomorpho-
metric 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: 422–430.
Camargo, P.M., Lekovic, V., Weinlaender, M., Klok-
kevold, P.R., Kenney, E.B., Dimitrijevic, B.,
Nadic, M., Jancovic, S. & Orsini, M. (2000) Influ-
ence of bioactive glass on changes in alveolar pro-
cess dimensions after exodontia. Oral Surgery
Oral Medicine Oral Pathology Oral Radiology &
Endodontology 90: 581–586.
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. Od-
ontologisk Revy 18: 27–54.
Crespi, R., Cappare, P. & Gherlone, E. (2009) Mag-
nesium-enriched hydroxyapatite compared to cal-
cium sulfate in the healing of human extraction
sockets: radiographic and histomorphometric
evaluation at 3 months. Journal of Periodontol-
ogy 80: 210–218.
Fiorellini, J.P., Howell, T.H., Cochran, D., Malm-
quist, 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-Ta’a, M.
& van Steenberghe, D. (2009) Bone healing after
dental extractions in irradiated patients: a pilot
© 2011 John Wiley & Sons A/S
Tan et al ! Dimensional tissue changes post extraction
posterior maxilla reduces the need for sinus aug-
mentation. International Journal of Periodontics
& Restorative Dentistry 30: 265–273.
Rodd, H.D., Malhotra, R., O’Brien, C.H., Elcock, C.,
Davidson, L.E. & North, S. (2007) Change in sup-
porting tissue following loss of a permanent max-
illary incisor in children. Dental Traumatology
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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 pro-
spective study in humans. Journal of Oral &
Maxillofacial Surgery 64: 1359–1365.
Schropp, L., Wenzel, A., Kostopoulos, L. & Karring,
T. (2003) Bone healing and soft tissue contour
changes following single-tooth extraction: a clini-
cal and radiographic 12-month prospective study.
International Journal of Periodontics & Restor-
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Jones, A. & Nevins, M. (2005) Randomized study
evaluating recombinant human bone morphoge-
netic protein-2 for extraction socket augmenta-
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Iasella, J.M., Greenwell, H., Miller, R.L., Hill, M.,
Drisko, C., Bohra, A.A. & Scheetz, J.P. (2003)
Ridge preservation with freeze-dried bone allo-
graft and a collagen membrane compared to
extraction alone for implant site development: a
clinical and histologic study in humans. Journal
of Periodontology 74: 990–999.
Kerr, E.N., Mealey, B.L., Noujeim, M.E., Lasho, D.
J., Nummikoski, P.V. & Mellonig, J.T. (2008) The
effect of ultrasound on bone dimensional changes
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Periodontology 79: 283–290.
Lekovic, V., Camargo, P.M., Klokkevold, P.R., We-
inlaender, M., Kenney, E.B., Dimitrijevic, B. &
Nedic, M. (1998) Preservation of alveolar bone in
extraction sockets using bioabsorbable mem-
branes. Journal of Periodontology 69: 1044–1049.
Lekovic, V., Kenney, E.B., Weinlaender, M., Han, T.,
Klokkevold, P., Nedic, M. & Orsini, M. (1997) A
bone regenerative approach to alveolar ridge main-
tenance following tooth extraction. Report of 10
cases. Journal of Periodontology 68: 563–570.
Moya-Villaescusa, M.J. & Sanchez-Pérez, A. (2010)
Measurement of ridge alterations following tooth
removal: a radiographic study in humans. Clini-
cal Oral Implants Research 21: 237–242.
Oghli, A.A. & Steveling, H. (2010) Ridge preserva-
tion following tooth extraction: a comparison
between atraumatic extraction and socket seal
surgery. Quintessence International 41: 605–609.
Pelegrine, A.A., da Costa, C.E., Correa, M.E. &
Marques, J.F. Jr (2010) Clinical and histomorpho-
study on a novel technique for volume assess-
ment of healing tooth sockets. Clinical Oral
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17 |
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the residual alveolar ridges in complete denture
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(2009) Alveolar bone dimensional changes of
post-extraction sockets in humans: a systematic
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1048–1058.
Yilmaz, S., Efeoglu, E. & Kilic, A.R. (1998) Alveolar
ridge reconstruction and/or preservation using
root form bioglass cones. Journal of Clinical Peri-
odontology 25: 832–839.
metric evaluation of extraction sockets treated
with an autologous bone marrow graft. Clinical
Oral Implants Research 21: 535–542.
Rasperini, G., Canullo, L., Dellavia, C., Pellegrini,
G. & Simion, M. (2010) Socket grafting in the
posterior maxilla reduces the need for sinus aug-
mentation. International Journal of Periodontics
& Restorative Dentistry 30: 265–273.
Rodd, H.D., Malhotra, R., O’Brien, C.H., Elcock, C.,
Davidson, L.E. & North, S. (2007) Change in sup-
porting tissue following loss of a permanent max-
illary incisor in children. Dental Traumatology
23: 328–332.
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 pro-
spective study in humans. Journal of Oral &
Maxillofacial Surgery 64: 1359–1365.
Schropp, L., Wenzel, A., Kostopoulos, L. & Karring,
T. (2003) Bone healing and soft tissue contour
changes following single-tooth extraction: a clini-
cal and radiographic 12-month prospective study.
International Journal of Periodontics & Restor-
ative Dentistry 23: 313–323.
Serino, G., Biancu, S., Iezzi, G. & Piattelli, A.
(2003) Ridge preservation following tooth extrac-
tion using a polylactide and polyglycolide sponge
as space filler: a clinical and histological study in
humans. Clinical Oral Implants Research 14:
651–658.
Yilmaz, S., Efeoglu, E. & Kilic, A.R. (1998) Alveolar
ridge reconstruction and/or preservation using
root form bioglass cones. Journal of Clinical Peri-
odontology 25: 832–839.
Exclusion criteria: reported parameters not
relevant or not useful.
Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Tan et al ! Dimensional tissue changes post extraction
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: 1133–1138.
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: 121–134.
Exclusion criteria: reported parameters not
relevant or not useful.
Altundal, H. & Guvener, O. (2004) The effect of
alendronate on resorption of the alveolar bone fol-
lowing tooth extraction. The International Jour-
nal of Oral & Maxillofacial Surgery 33: 286–293.
Exclusion criteria: reported parameters not
relevant or not useful.
Alves-Rezende, M.C. & Okamoto, T. (1997) Effects
of fibrin adhesive material (tissucol) on alveolar
healing in rats under stress. Brazilian Dental
Journal 8: 13–19.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Amemori, H. (1966) An experimental study of
changes in the form of the mandible after extrac-
tion of lower posterior teeth. I. The areal change
of mandibular frontal sections.. Bulletin of Tokyo
Medical & Dental University 13: 59–74.
Exclusion criteria: study carried out on ani-
mals.
Anitua, E. (1999) Plasma rich in growth factors: pre-
liminary results of use in the preparation of
future sites for implants. The International Jour-
nal of Oral & Maxillofacial Implants 14: 529–
535.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Araujo, M., Linder, E., Wennstrom, J. & Lindhe, J.
(2008) The influence of bio-oss collagen on heal-
ing of an extraction socket: an experimental
study in the dog. International Journal of Peri-
odontics & Restorative Dentistry 28: 123–135.
Exclusion criteria: reported parameters not
relevant or not useful.
Araujo, M.G. & Lindhe, J. (2005) Dimensional ridge
alterations following tooth extraction. An experi-
mental study in the dog.. Journal of Clinical Peri-
odontology 32: 212–218.
Exclusion criteria: only measured relative
difference in height between buccal and lin-
gual 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. Clin-
ical Oral Implants Research 20: 545–549.
18 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Exclusion criteria: no baseline data avail-
able for comparison, thus unable to arrive at
an estimate of dimensional change over time.
Araujo, M.G. & Lindhe, J. (2009b) Ridge preserva-
tion with the use of bio-oss collagen: a 6-month
study in the dog. Clinical Oral Implants
Research 20: 433–440.
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
Periodontology 32: 645–652.
Exclusion criteria: sample did not include
untreated/undisturbed extraction sockets left
to heal spontaneously.
Ashman, A. & Bruins, P. (1985) Prevention of alveo-
lar bone loss postextraction with htr grafting
material. Oral Surgery Oral Medicine & Oral
Pathology 60: 146–153.
Exclusion criteria: descriptive report on
procedure/technique; commentary.
Ashman, A. & Bruins, P. (1987) Prevention of alveo-
lar bone loss postextraction with htr polymer
grafting material. Journal of Oral Implantology
13: 270–281.
Exclusion criteria: descriptive report on
procedure/technique; commentary.
Bahat, O., Deeb, C., Golden, T. & Komarnyckij, O.
(1987) Preservation of ridges utilizing hydroxyapa-
tite. International Journal of Periodontics &
Restorative Dentistry 7: 34–41.
Exclusion criteria: sample did not include
untreated/undisturbed extraction sockets left
to heal spontaneously.
Bergstedt, H., Wictorin, L. & Lundquist, G. (1973)
Transplantation of bone treated with ethylenedia-
mine into tooth sockets in immediate denture
patients. Sven Tandlak Tidskr 66: 39–48.
Exclusion criteria: study subjects had
immediate dentures after extraction, hence
they did not have undisturbed healing post-
extraction.
Berkovitz, B.K. (1971) The healing process in the
incisor tooth socket of the rat following root
resection and exfoliation. Archives of Oral Biol-
ogy 16: 1045–1054.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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.
Exclusion criteria: reported parameters not
relevant or not useful.
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 &
Maxillofacial Surgery 17: 138–141.
Exclusion criteria: no measurements of
alveolar dimensional changes (e.g. description
of healing process or bony shape change, or
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: 470–473.
Exclusion criteria: reported parameters not
relevant or not useful.
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: 147–154.
Exclusion criteria: reported parameters not
relevant or not useful.
Cardaropoli, G., Araujo, M., Hayacibara, R., Sukek-
ava, 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 Clini-
cal Periodontology 32: 435–440.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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: 21–43.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Carmagnola, D., Adriaens, P. & Berglundh, T.
(2003) Healing of human extraction sockets filled
with bio-oss. Clinical Oral Implants Research
14: 137–143.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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:
354–358.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Fickl, S., Zuhr, O., Wachtel, H., Bolz, W. & Huerz-
eler, M. (2008b) Tissue alterations after tooth
extraction with and without surgical trauma: a
volumetric study in the beagle dog. Journal of
Clinical Periodontology 35: 356–363.
Exclusion criteria: study carried out on ani-
mals.
Fickl, S., Zuhr, O., Wachtel, H., Stappert, C.F.,
Stein, J.M. & Hurzeler, M.B. (2008c) Dimensional
© 2011 John Wiley & Sons A/S

changes of the alveolar ridge contour after differ-
ent socket preservation techniques. Journal of
Clinical Periodontology 35: 906–913.
Exclusion criteria: study carried out on ani-
mals.
Fickl, S., Zuhr, O., Wachtel, H., Bolz, W. & Huerz-
eler, M.B. (2008c) Hard tissue alterations after
socket preservation: an experimental study in the
beagle dog. Clinical Oral Implants Research 19:
1111–1118.
Exclusion criteria: no baseline data avail-
able for comparison, thus unable to arrive at
an estimate of dimensional change over time.
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 Periodontol-
ogy 70: 375–383.
Exclusion criteria: reported parameters not
relevant or not useful.
Gorustovich, A., Veinsten, F., Costa, O.R. & Gug-
lielmotti, M.B. (2004) Histomorphometric evalua-
tion of the effect of bovine collagen granules on
bone healing. An experimental study in rats. Acta
Odontologica Latinoamericana 17: 9–13.
Exclusion criteria: reported parameters not
relevant or not useful.
Green, L.J., Gong, J.K. & Neiders, M.E. (1969) Rela-
tionship between sr85 uptake and histological
changes during healing in dental extraction wounds
in rats. Archives of Oral Biology 14: 865–872.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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 & Maxil-
lofacial Surgery 43: 359–364.
Exclusion criteria: reported parameters not
relevant or not useful.
Guglielmotti, M.B., Ubios, A.M. & Cabrini, R.L.
(1985) Alveolar wound healing alteration under
uranyl nitrate intoxication. Journal of Oral
Pathology 14: 565–572.
Exclusion criteria: reported parameters not
relevant or not useful.
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.
Exclusion criteria: no baseline data avail-
able for comparison, thus unable to arrive at
an estimate of dimensional change over time.
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: 729–734.
Exclusion criteria: study carried out on ani-
mals.
Hars, E. & Massler, M. (1972) Effects of fluorides,
cortico-steroids and tetracyclines on extraction
© 2011 John Wiley & Sons A/S
Tan et al ! Dimensional tissue changes post extraction
wound healing in rats. Acta Odontologica Scan-
dinavica 30: 511–522.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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 Jour-
nal of Oral Surgery 8: 457–461.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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: 529–531.
Exclusion criteria: no baseline data avail-
able for comparison, thus unable to arrive at
an estimate of dimensional change over time.
Huebsch, R.F. & Hansen, L.S. (1969) A histopatho-
logic study of extraction wounds in dogs. Oral
Surgery Oral Medicine & Oral Pathology 28: 187
–196.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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: 835–840.
Exclusion criteria: reported parameters not
relevant or not useful.
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: 150–155.
Exclusion criteria: sample did not include
untreated/undisturbed extraction sockets left
to heal spontaneously.
Indovina, A. Jr & Block, M.S. (2002) Comparison of 3
bone substitutes in canine extraction sites. Journal
of Oral & Maxillofacial Surgery 60: 53–58.
Exclusion criteria: reported parameters not
relevant or not useful.
Kangvonkit, P., Matukas, V.J. & Castleberry, D.J.
(1986) Clinical evaluation of durapatite sub-
merged-root implants for alveolar bone preserva-
tion. The International Journal of Oral &
Maxillofacial Surgery 15: 62–71.
Exclusion criteria: study subjects had
immediate dentures after extraction, hence
they did not have undisturbed healing post-
extraction.
Lavelle, C.L. (1985) Preliminary study of mandibu-
lar shape after tooth loss. Journal of Prosthetic
Dentistry 53: 726–730.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Librus, H., Pietrokovski, J., Ulmanski, M. & Geda-
lia, I. (1973) The effect of fluoride on molar
19 |
socket healing in the rat. Archives of Oral Biol-
ogy 18: 1283–1289.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
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:
705–710.
Exclusion criteria: sample did not include
untreated/undisturbed extraction sockets left
to heal spontaneously.
Loo, W.D. (1968) Ridge preservation with immedi-
ate treatment dentures. Journal of Prosthetic
Dentistry 19: 5–11.
Exclusion criteria: descriptive report on
procedure/technique; commentary.
Luvizuto, E.R., Queiroz, T.P., Dias, S.M., Okamoto,
T., Dornelles, R.C., Garcia, I.R. Jr & Okamoto, R.
(2010) Histomorphometric analysis and immunol-
ocalization of rankl and opg during the alveolar
healing process in female ovariectomized rats
treated with oestrogen or raloxifene. Archives of
Oral Biology 55: 52–59.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Magro Filho, O. & de Carvalho, A.C. (1990) Appli-
cation of propolis to dental sockets and skin
wounds. Journal of Nihon University School of
Dentistry 32: 4–13.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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: 12–15.
Exclusion criteria: reported parameters not
relevant or not useful.
Mathai, J.K., Chandra, S., Nair, K.V. & Nambiar, K.
K. (1989) Tricalcium phosphate ceramic as imme-
diate root implants for the maintenance of alveo-
lar bone in partially edentulous mandibular jaws.
A clinical study. Australian Dental Journal 34:
421–426.
Exclusion criteria: reported parameters not
relevant or not useful.
Matsumoto, M. (1968) Changes in residual ridge of
the mandible after extraction and wearing exten-
sion saddle type of removable partial dentures. (a
longitudinal, clinical and roentgenographic inves-
tigation). Bulletin of Tokyo Medical & Dental
University 15: 67–89.
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: 142–155.
Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Tan et al ! Dimensional tissue changes post extraction
Exclusion criteria: study subjects had
immediate dentures after extraction, hence
they did not have undisturbed healing post-
extraction.
Minsk, L. (2005) Extraction-site ridge preservation.
Compendium of Continuing Education in Den-
tistry 26: 272.
Exclusion criteria: descriptive report on
procedure/technique; commentary.
Mizutani, H. & Ishihata, N. (1976) Decrease and
increase in residual ridges after extraction of
teeth in monkeys (part I). Bulletin of Tokyo Med-
ical & Dental University 23: 157–168.
Exclusion criteria: study carried out on ani-
mals.
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.
Exclusion criteria: reported parameters not
relevant or not useful.
Nevins, M.L., Camelo, M., Schupbach, P., Kim, D.
M., Camelo, J.M. & Nevins, M. (2009) Human his-
tologic evaluation of mineralized collagen bone
substitute and recombinant platelet-derived
growth factor-bb to create bone for implant place-
ment in extraction socket defects at 4 and
6 months: a case series. International Journal of
Periodontics & Restorative Dentistry 29: 129–139.
Exclusion criteria: sample did not include
untreated/undisturbed extraction sockets left
to heal spontaneously.
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 posi-
tion. World Journal of Orthodontics 11: 55–60.
Exclusion criteria: reported parameters not
relevant or not useful.
Olson, H.M. & Hagen, A. (1982) Inhibition of post-
extraction alveolar ridge resorption in rats by di-
chloromethane diphosphonate. Journal of Peri-
odontal Research 17: 669–674.
Exclusion criteria: study carried out on ani-
mals.
Olson, R.A., Roberts, D.L. & Osbon, D.B. (1982) A
comparative study of polylactic acid, gelfoam,
and surgicel in healing extraction sites. Oral Sur-
gery Oral Medicine & Oral Pathology 53: 441–
449.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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: 9–16.
20 | Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Exclusion criteria: study carried out on ani-
mals.
Ortega, K.L., Rezende, N.P., Araujo, N.S. & Ma-
galhaes, M.H. (2007) Effect of a topical antimicro-
bial paste on healing after extraction of molars in
hiv positive patients: randomised controlled clini-
cal trial. British Journal of Oral & Maxillofacial
Surgery 45: 27–29.
Exclusion criteria: reported parameters not
relevant or not useful.
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: 442–447.
Exclusion criteria: no baseline data avail-
able for comparison, thus unable to arrive at
an estimate of dimensional change over time.
Pietrokovski, J. (1967) Healing of the socket
following tooth extraction. Alpha Omegan 60:
126–129.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Pietrokovski, J. & Massler, M. (1967a) Alveolar
ridge resorption following tooth extraction. Jour-
nal of Prosthetic Dentistry 17: 21–27.
Exclusion criteria: length of observation
period not reported.
Pietrokovski, J. & Massler, M. (1967b) Ridge remod-
eling after tooth extraction in rats. Journal of
Dental Research 46: 222–231.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Pietrokovski, J. & Massler, M. (1971) Residual ridge
remodeling after tooth extraction in monkeys.
Journal of Prosthetic Dentistry 26: 119–129.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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: 3–9.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Puia, S.A., Renou, S.J., Rey, E.A., Guglielmotti, M.
B. & Bozzini, C.E. (2009) Effect of bismuth sub-
gallate (a hemostatic agent) on bone repair; a his-
tologic, radiographic and histomorphometric
study in rats. The International Journal of Oral
& Maxillofacial Surgery 38: 785–789.
Exclusion criteria: reported parameters not
relevant or not useful.
Quinn, J.H. & Kent, J.N. (1984) Alveolar ridge
maintenance with solid nonporous hydroxylapa-
tite root implants. Oral Surgery Oral Medicine &
Oral Pathology 58: 511–521.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Richardson, A. (1965) The pattern of alveolar bone
resorption following extraction of anterior teeth.
Dental Practitioner & Dental Record 16: 77–80.
Exclusion criteria: reported parameters not
relevant or not useful.
Rothamel, D., Schwarz, F., Herten, M., Engelhardt,
E., Donath, K., Kuehn, P. & Becker, J. (2008)
Dimensional ridge alterations following socket
preservation using a nanocrystalline hydroxyapa-
tite paste: a histomorphometrical study in dogs.
The International Journal of Oral & Maxillofa-
cial Surgery 37: 741–747.
Exclusion criteria: no baseline data avail-
able for comparison, thus unable to arrive at
an estimate of dimensional change over time.
Sattayasanskul, W., Brook, I.M. & Lamb, D.J. (1988)
Dense hydroxyapatite root replica implantation:
measurement of mandibular ridge preservation.
The International Journal of Oral & Maxillofa-
cial Implants 3: 203–207.
Exclusion criteria: study subjects had
immediate dentures after extraction, hence
they did not have undisturbed healing post-
extraction.
Scheer, P. & Boyne, P.J. (1987) Maintenance of alve-
olar bone through implantation of bone graft sub-
stitutes in tooth extraction sockets. Journal of
the American Dental Association 114: 594–597.
Exclusion criteria: descriptive report on
procedure/technique; commentary.
Sclar, A.G. (1999) Preserving alveolar ridge anatomy
following tooth removal in conjunction with
immediate implant placement. The bio-col tech-
nique. Atlas of the Oral & Maxillofacial Surgery
Clinics of North America 7: 39–59.
Exclusion criteria: descriptive report on
procedure/technique; commentary.
Serino, G., Rao, W., Iezzi, G. & Piattelli, A. (2008)
Polylactide and polyglycolide sponge used in
human extraction sockets: bone formation fol-
lowing 3 months after its application. Clinical
Oral Implants Research 19: 26–31.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Sharan, A. & Madjar, D. (2008) Maxillary sinus
pneumatization following extractions: a radio-
graphic study. The International Journal of Oral
& Maxillofacial Implants 23: 48–56.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Shi, B., Zhou, Y., Wang, Y.N. & Cheng, X.R. (2007)
Alveolar ridge preservation prior to implant place-
ment with surgical-grade calcium sulfate and
platelet-rich plasma: a pilot study in a canine
© 2011 John Wiley & Sons A/S

model. The International Journal of Oral & Max-
illofacial Implants 22: 656–665.
Exclusion criteria: study carried out on ani-
mals.
Smith, N. (1974) A comparative histological and
radiographic study of extraction socket healing in
the rat. Australian Dental Journal 19: 250–254.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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 heal-
ing after tooth extraction. Archives of Oral Biol-
ogy 46: 375–379.
Exclusion criteria: reported parameters not
relevant or not useful.
© 2011 John Wiley & Sons A/S
Tan et al ! Dimensional tissue changes post extraction
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: 177–181.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
histology only).
Thilander, H. & Astrand, P. (1973) The effect of tet-
racyclines on socket healing. Acta Odontologica
Scandinavica 31: 131–139.
Exclusion criteria: no measurements of
alveolar dimensional changes (eg. description
of healing process or bony shape change, or
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: 322–324.
21 |
Exclusion criteria: reported parameters not
relevant or not useful.
Wu, Z., Liu, C., Zang, G. & Sun, H. (2008) The
effect of simvastatin on remodelling of the alveo-
lar bone following tooth extraction. The Interna-
tional Journal of Oral & Maxillofacial Surgery
37: 170–176.
Exclusion criteria: sample did not include
untreated/undisturbed extraction sockets left
to heal spontaneously.
Yugoshi, L.I., Sala, M.A., Brentegani, L.G. & Lama-
no Carvalho, T.L. (2002) Histometric study of
socket healing after tooth extraction in rats trea-
ted with diclofenac. Brazilian Dental Journal 13:
92–96.
Exclusion criteria: sample did not include
untreated/undisturbed extraction sockets left
to heal spontaneously.
Clin. Oral. Impl. Res. 23(Suppl. 5), 2012/1–21
Copyright of Clinical Oral Implants Research is the property of Wiley-Blackwell and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.
 Osteology Consensus Report
Christoph H.F. Hämmerle Evidence-based knowledge on the
Mauricio G. Araujo
Massimo Simion
biology and treatment of extraction
Mauricio G. Araujo sockets

Authors’ affiliations:
Christoph H.F. Hämmerle, Center of Dental
Medicine, Clinic of Fixed and Removable
Prosthodontics and Dental Material Science,
University of Zurich, Zurich, Switzerland
Mauricio G. Araujo, Department of Dentistry, State
University of Maringá, Parana, Brazil
Massimo Simion, Departmet of Periodontology,
IRCCS Cà Granda Foundation – Ospedale Maggiore
Policlinico, Department of Reconstructive, Surgical
and Diagnostic Science, University of Milan,
Department of Periodonology, College of Dentistry,
King Saud University, Riyadh, Saudi Arabia
Mauricio G. Araujo, Department of Dentistry, State
University of Maringá, Parana, Brazil
Corresponding author:
Mauricio G. Araujo
Department of Dentistry
State University of Maringá
Parana, Brazil
Tel.: +41 44 634 32 51
Fax: +41 44 634 43 05
e-mail: christoph.hammerle@zzm.uzh.ch
Conflicts of interest
The authors declare no conflicts of interest.
Key words: bone regeneration, clinical research, clinical trials, guided tissue regeneration,
wound healing
Abstract
Objectives: The fresh extraction socket in the alveolar ridge represents a special challenge in
everyday clinical practice. Maintenance of the hard and soft tissue envelope and a stable ridge
volume were considered important aims to allow simplifying subsequent treatments and
optimizing their outcomes in particular, when implants are planned to be placed.
Material and Methods: : Prior to the consensus meeting four comprehensive systematic reviews
were written on two topics regarding ridge alteration and ridge preservation following tooth
extraction and implant placement following tooth extraction. During the conference these
manuscripts were discussed and accepted thereafter. Finally, consensus statements and
recommendations were formulated.
Results: : The systematic reviews demonstrated that the alveolar ridge undergoes a mean
horizontal reduction in width of 3.8 mm and a mean vertical reduction in height of 1.24 mm
within 6 months after tooth extraction. The techniques aimed at ridge preservation encompassed
two different approaches: i) maintaining the ridge profile, ii) enlarging the ridge profile.
Regarding timing of implant placement the literature showed that immediate implant placement
leads to high implant survival rates. This procedure is primarily recommended in premolar sites
with low esthetic importance and favorable anatomy. In the esthetic zone, however, a high risk for
mucosal recession was reported. Hence, it should only be used in stringently selected situations
with lower risks and only by experienced clinicians. In molar sites a high need for soft and hard
tissue augmentation was identified.
Conclusions: : Future research should clearly identify the clinical and patient benefits resulting
from ridge preservation compared with traditional procedures. In addition, future research should
also aim at better identifying parameters critical for positive treatment outcomes with immediate
implants. The result of this procedure should be compared to early and late implant placement.

*Osteology Consensus Group 2011: Mauricio G. Araújo,
Maringa, Parana, Brazil; Dieter Bosshardt, Daniel Buser,
Berne, Switzerland; William V. Giannobile, Ann Arbor,
Michighan, USA; Reinhard Gruber, Vienna, Austria; Chr-
istoph H.F. Hämmerle, Ronald E. Jung, Zürich, Switzer-
land; Niklaus P. Lang, Hong Kong SAR PRC; Myron
Nevins, Boston, Massachusetts, USA; Friedrich Neukam,
Nuremberg, Germany; Mariano Sanz, Madrid, Spain;
Massimo Simion, Milano, Italy; Georg Watzek, Vienna,
Austria
Date:
Accepted 8 October 2011
To cite this article:
CHF Hämmerle, Araújo MG, Simion M, On Behalf of the
Osteology Consensus Group 2011. Evidence-based knowledge
on the biology and treatment of extraction sockets.
Clin. Oral Impl. Res. 23(Suppl. 5), 2012, 80–82
doi: 10.1111/j.1600-0501.2011.02370.x
The fresh extraction socket in the alveolar
ridge represents a special challenge in every-
day clinical practice. Regardless of the subse-
quent treatment maintenance of the ridge
contour will frequently facilitate all further
steps of therapy. This is particularly true for
treatments involving the placement and
reconstruction of dental implants. It has been
demonstrated in numerous animal and clini-
cal studies in humans that following tooth
extraction undisturbed wound healing will
lead to loss of ridge volume and change in
ridge shape.
The aim of the present consensus report
was to critically evaluate the scientific evi-
dence regarding ridge alterations following
tooth extraction and to assess the effects of
treatment strategies aiming at preservation of
the ridge following tooth extraction. Further-
more, this consensus analyzed the clinical
outcomes of implant placement into sockets
at different time spans following tooth
extraction.
Workshop discussion and
consensus
The group discussing the evidence and gener-
ating the consensus statements consisted of
individuals competent in different disciplines
of medical dentistry with a special emphasis
on implant therapy. Prior to the consensus
meeting, two groups of researchers wrote
comprehensive systematic reviews on two
topics each regarding ridge alterations and

© 2011 John Wiley & Sons A/S 80


ridge preservation following tooth extraction
and implant placement following tooth
extraction.
During the conference, the reviewers first
presented their manuscripts explaining how
the literature search was conducted, how the
data were extracted, analyzed, which results
were found and which conclusions could be
drawn. The entire group then discussed these
reports. Thereafter, all four manuscripts were
accepted. Another thorough discussion fol-
lowed on published data on lower levels of
evidence than the one included in the manu-
scripts and its impact on the conclusions to
be drawn. Finally, the group formulated con-
sensus statements and recommendations for
clinical practice and for future research.
Ridge preservation
Definition of terms
The group considered it important to define
terms regarding the various procedures,
which previously had been described in the
literature under the general term of “ridge
preservation.” It was obvious that a distinc-
tion needed to be made as described below.
Ridge preservation = preserving the ridge
volume within the envelope existing at the
time of extraction
Ridge augmentation = increasing the ridge
volume beyond the skeletal envelope existing
at the time of extraction
Consensus statements regarding ridge
preservation
The systematic review by Lang et al. (2012)
demonstrated that based on clinical studies
the alveolar ridge undergoes the following
dimensional changes within 6 months after
tooth extraction:
• Mean horizontal reduction in ridge width:
3.8 mm.
• Mean vertical reduction in ridge height:
1.24 mm.
Based on the systematic review by Vigno-
letti et al. (2012) the group concluded that
the reasons for ridge preservation included:
• Maintenance of the existing soft and hard
tissue envelope.
• Maintenance of a stable ridge volume for
optimizing functional and esthetic out-
comes.
• Simplification of treatment procedures
subsequent to the ridge preservation
© 2011 John Wiley & Sons A/S
Hämmerle et al ! Evidence for treatment of extraction sockets
(i) Generation of a good soft tissue volume
for the time of implant placement thus
simplifying implantation procedures at
earlier time points.
(ii) Generation of a good hard tissue volume
for the time of implant placement thus
simplifying implantation procedures at
later time points.
No high level evidence was found in the
literature regarding contraindications specific
for ridge preservation. Hence, the group made
the following consensus.
Contraindication for ridge preservation was
considered to encompass:
• General contraindication against oral sur-
gical interventions.
Furthermore:
• Infections at the site planned for ridge
preservation, which cannot be taken care
of during the ridge preservation surgery.
• Patients radiated in the area planned for
ridge preservation.
• Patients taking bisphosphonates.
Various techniques have been described in
the literature for so called ridge preserva-
tion. These techniques may be categorized
into two different groups: (i) techniques aim-
ing at maintaining the ridge profile (ridge
preservation), (ii) techniques aiming at
enlarging the ridge profile (ridge augmenta-
tion).
To enlarge the ridge profile flaps have
generally been raised and augmentation pro-
cedures using biomaterials for ridge contour-
ing with or without barrier membranes
have been performed. It appears that pri-
mary closure of the wound is beneficial
regarding the volume gained applying this
approach.
These indications were identified for ridge
preservation:
• Implant placement is planned at a time
point later than tooth extraction i.e.,
(i) When immediate or early implanta-
tion is not recommendable
(ii) When patients are not available for
the immediate or early implant
placement (pregnancy, holidays, …)
(iii) When primary stability of an
implant cannot be obtained
(iv) In adolescent people
• Contouring of the ridge for conventional
prosthetic treatment.
• Provided the cost/benefit ratio is positive.
• Reducing the need for elevation of the
sinus floor.
Regarding indication other than the ones
mentioned above, there is little or no evi-
dence.
Clinical recommendations regarding ridge
preservation
In general, the group made the following clin-
ical recommendations:
• Raising of a flap and placement of bioma-
terials (biomaterial for ridge contouring
and/or barrier membrane).
• Primary would closure.
• Materials with a low resorption and
replacement rate.
• Raising of flaps and placement of a
device/devices for contouring the ridge
profile.
Regarding the different materials applied in
clinical studies the systematic review did not
show significant differences between the var-
ious materials, (i.e., filler, membranes) except
for the collagen plug alone, which revealed
negative results.
Although primary wound closure was gen-
erally considered an important factor for suc-
cess, the literature did not allow a
meaningful comparison of different tech-
niques for primary wound closure (soft tissue
punch, connective tissue graft, barrier mem-
brane, soft tissue replacement matrix).
Future research regarding ridge preservation
Regarding future research the consensus sta-
ted the following:
• Focus on patient centered outcomes.
• Focus on clinical short-, medium-, and
long-term outcomes including biological,
technical, phonetic, and esthetic parame-
ters.
• Studies regarding possible benefits during
subsequent implant therapy encompass-
ing:
(i) Assessing the need for further hard and
soft tissue augmentation
(ii) Assessing the amount of further hard
and soft tissue augmentation.
(iii) Assessing esthetic outcomes.
• Conditions of the soft tissues, i.e., dis-
placement of the muco-gingival junction,
color of the ridge mucosa, amount of ker-
atinized mucosa.
• Techniques for soft tissue management, i.
•
e., raising of flaps yes/no.
Method for soft tissue closure.
• Influence of the hard and soft tissue anat-
omy following tooth extraction: presence
or absence of bony socket walls, thick-
81 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/80–82
Hämmerle et al ! Evidence for treatment of extraction sockets
ness of the bony socket walls, soft tissue
area, volume, color, scars.
• Effect of various biomaterials applied for
ridge contouring.
• Effect of various biomaterials applied as
barrier membranes.
• Methodological studies on the optimal
type of measurements to assess the out-
come of treatment regarding soft tissue
and hard tissues.
• Development of consistent reference
points for 3D imaging technologies, when
studying changes in ridge morphology
regarding soft and/or hard tissues.
• Studies on the normal anatomy regarding
bone and soft tissue thickness and types
in different regions of the jaws.
• Studies on the effects of different extrac-
tion techniques on subsequent healing.
• Identify the most appropriate control
group for pre-clinical and clinical studies.
Timing for implant placement
Two systematic reviews were available (Lau
et al. 2012; Sanz et al. 2012) regarding timing
of implant placement into extraction sockets.
Both reviews focused on the highest level of
scientific evidence and were conducted with
reasonable and clearly defined inclusion and
exclusion criteria.
Consensus statements regarding timing for
implant placement
Limited to esthetic sites the systematic
reviews lead to following conclusions:
• Immediate implant placement leads to
high implant survival rates.
• Immediate implant placement is associ-
ated with a high risk for mucosal recession.
A wide range regarding the amount of
recessions is reported in the literature.
References
Belser, U.C., Grütter, L., Vailati, F., Bornstein, M.
M., Weber, H.-P. & Buser, D. (2009) Outcome
evaluation of early placed maxillary anterior sin-
gle-tooth implants using objective esthetic crite-
ria: a cross-sectional, retrospective study in 45
patients with a 2- to 4-year follow-up using pink
and white esthetic scores. Journal of Periodontol-
ogy 80: 140–151.
Buser, D., Wittneben, J., Bornstein, M.M., Grütter,
L., Chappuis, V. & Belser, U.C. (2011) Stability of
contour augmentation and esthetic outcomes of
implant-supported single crowns in the esthetic
82 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/80–82
• Several risk factors for the development
of mucosal recession have been identified:
(i) Smoking
(ii) Presence of a thin buccal bone plate
(i.e., <1 mm thick)
(iii) Presence of a thin soft tissue biotype
(iv) Facial implant position
• Augmentation of soft and hard tissues is
frequently necessary.
• The procedure of immediate implant place-
ment into extraction sockets should be
used very restrictively in the esthetic area.
Limited to posterior sites the systematic
review by Lau et al. 2012 lead to the follow-
ing conclusions:
• For single tooth implants high survival
and low complication rates have been
reported.
• Molar sites present situations with lim-
ited indications due to anatomical rea-
sons.
• When immediate implants are placed in
molar sites, soft and hard tissue augmen-
tation is frequently necessary.
• Premolars represent the sites with the
most favorable indication due to the nor-
mally favorable anatomical situation and
the generally low esthetic demands.
The treatments of fully edentulous jaws
and of multiple extraction sites have not
been duly addressed in the literature.
Clinical recommendations regarding timing for
implant placement
As based on the literature the group con-
cluded that in situations, where no risk fac-
tors are present (situations rarely occurring),
this procedure may be recommended for
experienced clinicians.
Immediate implant placement is primarily
recommended in premolar sites with low
esthetic importance and favorable anatomy.
zone: 3-year results of a prospective study with
early implant placement postextraction. Journal
of Periodontology 82: 342–349.
Lang, N.P., Pun, B.L., Lau, I.K.Y., Li, K.Y. & Wong,
M.C.M. (2012) A systematic review on survival
and success rates of implants placed immediately
into fresh extraction sockets after at least one
year. Clinical Oral Implants Research 23(Suppl.
5): 39–66.
Sanz, I., Garcia-Gargallo, M., Herrara, D., Martin,
C., Figuero, E. & Sanz, M. (2012) Surgical proto-
cols for early implant placement in post-extrac-
In areas of esthetic priority implant installa-
tion into the fresh extraction socket (Type I
placement) is not recommended.
Several published prospective case series
not included in the present systematic review
using the early implant placement protocol
have reported intermediate to long-term
excellent esthetic results (Belser et al. 2009;
Buser et al. 2011). These results lend addi-
tional support to the recommendation of type
II instead of type I implant placement follow-
ing tooth extraction in esthetic sites.
Future research regarding timing for implant
placement
These recommendations are valid for both
anterior and posterior sites.
• Reporting of frequency analyses of com-
plication should become standard.
• Studies addressing immediate implanta-
tion in the absence of risk factors.
• Comparison of surgical approaches with
and without the elevation of flaps.
• Comparison of surgical approaches with
and without filler materials in the gap
between the buccal aspect of the implant
and the buccal bone wall.
• Assess the influence of the distance of
the implant to the buccal bone wall on
bone formation.
• Comparison of different filler materials in
different clinical situations.
• Comparison of type 1 (immediate) and
type 2 (early) implant placement in low
risk situations.
• Comparison of type 2 (early) and type 3
(delayed) implant placement.
• Identify the ideal clinical protocols and
the best biomaterials for type 1, type 2,
and type 3 implant placement.
• Changes in the contours of the ridge over
extended periods of time.
tion sockets. A systematic review. Clinical Oral
Implants Research 23(Suppl. 5): 67–79.
Tan, W.L., Wong, T.W.L., Wong, M.C.M. & Lang,
N.P. (2012) A systematic review of post-extract-
ional alveolar bone dimensional changes in
humans. Clinical Oral Implants Research 23
(Suppl. 5): 1–21.
Vignoletti, F., Matesanz, P., Rodrigo, D., Figuero,
E., Martin, C. & Sanz, M. (2012) Surgical proto-
cols for ridge preservation after tooth extraction.
A systematic review. Clinical Oral Implants
Research 23(Suppl. 5): 22–38.
© 2011 John Wiley & Sons A/S
Copyright of Clinical Oral Implants Research is the property of Wiley-Blackwell and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.
The International Journal of Periodontics & Restorative Dentistry
 71

Ridge Preservation With and

Without Primary Wound Closure:
A Case Series

David M. Kim, DDS, DMSc1/Nicola De Angelis, DDS2/Marcelo Camelo, DDS3 Tooth extraction may lead to dif-
Marc L. Nevins, DMD, MMSc4/Peter Schupbach, PhD5/Myron Nevins, DDS6 ferent patterns of bone resorption,
apposition, and remodeling that
The purpose of this study was to determine the clinical and histologic efficacy make it difficult to predict the fi-
of the combination of alloplastic biphasic calcium phosphate composed of 30%
nal ridge contour and dimension.
hydroxyapatite and 70% β–tricalcium phosphate (Osteon II) and a cross-linked
collagen membrane used to reconstruct an extraction socket with new bone The clinician’s decision to augment
formation. Twelve patients, from two private dental practices, requiring extraction of extraction sockets is important be-
maxillary and mandibular nonmolar teeth (n = 30) received both Osteon II (0.5- to cause ungrafted extraction sockets
1.0-mm particle size) and the collagen membrane. The primary healing intention may undergo progressive bone
group (group A, n = 12) received primary flap closure over the membrane, while resorption without intervention.1–3
in the secondary healing intention group (group B, n = 18), the membrane was left
Complete bone regeneration to
exposed. Early wound healing seemed to be slower in group B when compared
to group A, but the difference was not noticeable after 4 weeks. Clinical reentry the pre-extraction crestal bone
revealed that the dimensions of the ridge appeared to be maintained in both level is not always possible, regard-
groups, and internal socket bone fill was evident. The grafted area appeared less of grafting materials or the use
to be well vascularized, but clinically visible graft particles were noted in some of barrier membranes.2–4
cases. Light microscopic analysis revealed the formation of new bone directly Autogenous bone has been
apposing the surfaces of graft particles and bridging the space between them,
considered the gold standard for
indicating that the graft material behaved as an osteoconductive scaffold. The
mean amount of vital bone in group A was 40.3% ± 7.8%, while the remaining bone grafting, but the morbidity
graft was 6.0% ± 4.0%. The mean amount of vital bone in group B was 47.3% ± and complications associated with
11.3%, while the remaining graft was 18.0% ± 20.0%. The absence of primary harvesting have provided a reason
flap closure did not affect the percentage of vital bone formation or residual graft. to consider alternatives. Alloplas-
(Int J Periodontics Restorative Dent 2013;33:71–78. doi: 10.11607/prd.1463) tic biomaterials such as hydroxy-
1Assistant Professor, Division of Periodontology, Department of Oral Medicine, Infection
apatite (HA) and β–tricalcium
and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts, USA. phosphate (β-TCP) are promising
2Assistant Professor, University of Genoa, Genoa, Italy.
bone substitutes because of their
3Institute for Advanced Dental Studies, Belo Horizonte, Brazil.

4Assistant Clinical Professor, Division of Periodontology, Department of Oral Medicine, Infection unlimited supply, but a lack of evi-
and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts, USA. dence and inconsistent clinical re-
5Schupbach Ltd, Service and Research for Histology, Microscopy and Imaging, Horgen, Switzerland.
ports have made clinicians weary
6Associate Clinical Professor, Division of Periodontology, Department of Oral Medicine, Infection

and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts, USA.

of their use.5–8
A barrier membrane is com-
Correspondence to: Dr David M. Kim, Harvard School of Dental Medicine, 188 Longwood Ave, monly used in conjunction with a
Boston, MA 02115, USA; fax: 617-432-1897; email: dkim@hsdm.harvard.edu.
bone graft to maintain space and
©2013 by Quintessence Publishing Co Inc. foster selective osteogenic cells

Volume 33, Number 1, 2013

72

Fig 1 The patient presented with a failed root canal treatment Fig 2 Atraumatic extraction was performed to preserve the buccal
and recurrent caries beneath the crown margins on the maxillary plate, and both sockets were grafted with Osteon II.
left canine and second premolar. Implants were selected to replace
the two teeth.

to populate the defect while ex-
cluding epithelial cells and fibro-
blasts.9 Resorbable membranes
are accompanied by fewer adverse
events than nonresorbable mem-
branes when exposed because
they degrade naturally.10,11 Ex-
posed non–cross-linked collagen
membranes may resorb too quickly
to accommodate bone formation,
while cross-linked collagen mem-
branes may allow stabilization of
the collagen fibers to maintain the
membrane’s integrity.11,12
The purpose of this study was
to determine the clinical and histo-
logic efficacy of the combination of
alloplastic biphasic calcium phos-
phate composed of 30% HA and
70% β-TCP (Osteon II, Dentium)
and a cross-linked collagen mem-
brane (Collagen Membrane,
Dentium) used to reconstruct an
extraction socket with new bone
formation. In addition, the safety
and efficacy of soft and hard tis-
sue regeneration in sites with in-
tentional exposure of the collagen
membrane was investigated.
Method and materials
Twelve patients (2 men, 10 women;
age range, 33 to 70 years), from two
private dental practices, requiring
extraction of maxillary and mandib-
ular nonmolar teeth (n = 30) partici-
pated in this outpatient study. They
required removal of one or more
teeth and expressed a desire for
replacement with dental implants.
Patients were systemically healthy
with no surgical contraindications.
Oral and written explanations of
the study, including the risks, bene-
fits, and alternative therapies, were
thoroughly discussed. All patients
volunteered for the protocol and
signed an informed consent form
based on the Helsinki Declaration
of 1975, as revised in 2000. Preop-
erative assessments including intra-
oral examination, and radiographic
evaluations (periapical radiographs
and computed tomography [CT]
scans) were performed.
The surgical procedure was
performed under local anesthe-
sia (2% xylocaine with 1:100,000
epinephrine). An intrasulcular inci-
sion was extended along the study
teeth followed by elevation of buc-
cal and lingual full-thickness flaps
(Fig 1). Atraumatic tooth extrac-
tions were performed to minimize
trauma to the socket walls, and
careful investigation was done to
identify possible bone dehiscences
and fenestrations. Sockets with a
thin or partially missing labial plate
(< 50%) were selected to undergo
the proposed ridge regeneration.
Thirty extraction sockets re-
ceived both Osteon II (0.5- to
1.0-mm particle size) and Collagen
membrane. The primary healing
intention group (group A, n = 12)
received primary flap closure over
the membrane, while in the sec-
ondary healing intention group

The International Journal of Periodontics & Restorative Dentistry


Fig 3 Collagen membrane placed to protect the underlying graft
material.
(group B, n = 18), the membrane
was left exposed. All extraction
sites were incrementally graft-
ed with Osteon II until the graft
was level with the existing crestal
bone, and a barrier membrane
was trimmed and closely adapted
to fit the contours of the grafted
site (Figs 2 and 3). Simple inter-
rupted sutures (Silk and Vicryl,
Ethicon) were used to position
the flap over the augmented area
(Fig 4). Both verbal and written
postoperative instructions were
given to patients, and appropri-
ate antibiotics and analgesics were
prescribed. Sutures were removed
7 to 10 days postsurgery, and pa-
tients were seen at regular intervals
during the 6 months of healing.
Postoperative periapical ra-
diographs and a CT scan were
obtained 6 months after the ridge
regeneration procedure prior to
the implant surgery. Soft and hard
tissue biopsy specimens of the
grafted areas were obtained using
Fig 4 Membrane intentionally exposed at both grafted sites.
either 3- or 4-mm trephine burs
(Dentium) along the long axis of the
treated sites prior to implant place-
ment. Twenty-three cores were ob-
tained (11 from group A, 12 from
group B). The collected cores were
kept in the trephine burs, placed
in formalin, and shipped to a his-
tologist. Tapered dental implants
(SuperLine, Dentium) were placed
into the biopsy sites, and primary
stability was verified in all cases.
Light microscopy
The bone cores were embedded
following complete dehydration
in ascending grades of ethanol in
a light-curing one-component res-
in (Technovit 7200 VLC, Heraeus
Kulzer). Polymerized blocks were
initially ground to bring the tissue
components closer to the cutting
surface. A 100-µm-thick section
was cut away from the block us-
ing a bandsaw equipped with a
73
diamond-coated blade (Exakt).
The final thickness of 40 μm was
achieved by grinding and final pol-
ishing steps with 1,200-, 2,400-,
and 4,000-grit sandpaper. Sec-
tions from each block were used
for staining with Sanderson rapid
bone stain (methylene blue and so-
dium permanganate).
Backscatter scanning electron
microscopy
Following the light microscopic
evaluation, the ground sections
were destained by polishing with
6-μm diamond paste. They were
then washed and sputter-coated
with a 6-nm-thick carbon layer
and examined in the backscatter
modus of a Supra 40VP scanning
electron microscope (Zeiss). Back-
scatter scanning electron micros-
copy (BSEM) micrographs were
produced from the same levels as
those for light microcopy.
Volume 33, Number 1, 2013
74

Fig 5 Excellent soft tissue healing was observed at the 15-week

postoperative visit.

Figs 6a and 6b Six-month postoperative CT scans revealed

preserved ridge dimensions of the sockets as well as radiographic
maturation of bone grafts for the (a) canine and (b) second premolar.

Results
Clinical and radiographic
evaluations
All 12 patients completed the study
without significant adverse events or
complications (Fig 5). Early wound
healing seemed to be slower at the
intentionally exposed sites (group B)
when compared to primary flap
closure sites (group A), but the dif-
ference was not noticeable after
4 weeks. Continuous maturation of
the tissue covering the membrane
was noted after 4 weeks in group B.
No spontaneous membrane expo-
sure was noted in group A.
Radiographic analysis revealed
that mesial and distal crestal bone
levels were maintained in both
groups. Sockets in both groups un-
derwent similar radiographic matu-
ration (Figs 6a and 6b).
The soft tissue that formed
over the exposed membrane ap-
peared to be firm in texture at the
6-month biopsy sampling. The re-
sistance of the regenerated bone
to trephine and osteotomy drills
indicated that the regenerated
bone was dense and firm. Clinical
reentry was performed after rais-
ing a full-thickness flap to assess
the quality of regenerated bone.
The dimensions of the ridge ap-
peared to be maintained in both
groups, and internal socket bone
fill was evident (Fig 7). The grafted
area appeared to be well vascu-
larized, but clinically visible graft
particles were noted in some cas-
es. The buccolingual dimensions
of the augmented alveolar ridge
allowed placement of dental im-
plants that were at least 4.5 mm
in width.
Light microscopy and BSEM
analyses
Histologic evaluation of the bone
cores from the augmented area
provided an opportunity to ex-
amine the quality and quantity of
newly formed bone and remnants
of grafting material (Figs 8 to 12).
The connective tissue was devoid
of inflammatory cell infiltrate but
was characterized by the presence
of a dense network of collagen fi-
bers with no membrane remnants
(Figs 8b and 11b). Evidence of
mature bone formation and resid-
ual bone grafting material was ob-
served to varying degrees (Figs 8b
and 11b). Newly formed bone
seemed to be directly apposed to
the surfaces of graft particles and
bridged the space between them,
indicating that the graft material
behaved as an osteoconductive

The International Journal of Periodontics & Restorative Dentistry

 75

500 μm
a
NB M NB G

500 μm
b
Fig 7 Clinical reentry with a full-thickness Figs 8a and 8b (a) BSEM and (b) light microscopic micrograph from the same section
flap revealed that the dimensions of the through a core showing new bone formation (NB), marrow space (M), and graft particles
ridge were maintained, and internal socket (G) (group A).
bone fill was evident.

Osteoblasts
Osteoid

NB
NB
NB

500 μm 50 μm

Fig 9 Light microscopic micrograph showing newly formed bone Fig 10 Ongoing bone formation was characterized by the pres-
(NB) and marrow space (M) (group A). ence of osteoblasts and osteoid (group A). NB = new bone.

Figs 11a and 11b (a) BSEM and (b) light

microscopic micrograph from the same
section through a core showing new bone
formation (NB), marrow space (M), and
graft particles (G) (group B). CT = connec-
500 μm
tive tissue. a
NB G G M NB G CT

500 μm
b

Volume 33, Number 1, 2013

76
G
NB
scaffold (Fig 12). The presence of
both osteoblasts and osteoclasts
indicated active bone formation as
well as bone remodeling.
BSEM evaluation of cores
confirmed the presence of newly
formed bone surrounding the graft
particles (Figs 8a and 11a). BSEM
enabled the graft particles to be dis-
tinguished from bone and nonmin-
eralized tissue by their more dense
and whiter appearance and shape.
Histomorphometric analysis
Histomorphometric analysis was
performed on 10 selected speci-
mens (5 from group A, 5 from
group B). There were no signifi-
cant differences between the two
groups regarding the amount of vi-
tal bone and residual graft (P > .05).
The mean amount of vital bone in
group A was 40.3% ± 7.8%, while
the remaining graft was 6.0% ±
4.0%. The mean amount of vi-
tal bone in group B was 47.3% ±
11.3%, while the remaining graft
The International Journal of Periodontics & Restorative Dentistry
Fig 12 Graft particles (G) were seen partially embedded in newly
formed bone (NB) (group B).
NB
G
G
NB
was 18.0% ± 20.0%. Therefore, the
absence of primary flap closure did
not affect the percentage of vital
bone formation or residual graft.
Discussion
Ridge preservation immediately
after tooth extraction has been ad-
vocated to preserve the ridge and
soft tissue dimension to allow ideal
implant placement.3,13 Ideal bone
substitutes should not only pre-
serve the socket dimension but also
encourage new bone ingrowth into
the grafted area, thereby forming a
living bridge between the existing
bone, new bone, and remaining
bone substitutes.14 With time, newly
formed bone should penetrate and
replace much of the graft through
the bone remodeling process.14
This study investigated the role
of an alloplastic biomaterial and
collagen membrane in preserv-
ing the ridge dimension after the
extraction of teeth. The biocom-
patibility and osteoconductivity of
the combination of HA and β-TCP
have been previously reported.15–22
Osteon II is composed of 30% HA
and 70% β-TCP (granules are 70%
porous with interconnected pores
of 250 μm). The reason to combine
an insoluble HA with a resorbable
β-TCP is that the slow-resorbing
HA will maintain the volume while
the faster-resorbing β-TCP will pro-
mote bone regeneration.
This study provided a healing
period of 6 months to induce incor-
poration of the grafts with subse-
quent maturation of newly formed
bone tissue. A similar amount of
bone regeneration as well as pres-
ervation of alveolar ridge dimen-
sions was observed in both primary
and secondary healing intention
groups. It was apparent that after a
6-month healing period, the graft-
ed area was stable enough to en-
sure successful implant placement.
Histologic analysis of obtained
bone cores revealed intimate con-
tact between mineralized bone
tissue and graft particles, confirm-
ing the osteoconductive property

of the biomaterial. The percent-
age of vital bone volume (40.3%
for group A and 47.3% for group
B) was equivalent to other studies
of HA and β-TCP composite bone
graft. For example, Froum et al16
reported a 28.35% mean vital bone
volume when a mixture of 60% HA
and 40% β-TCP was used as a sinus
augmentation material. While the
amount of vital bone formed after
the augmentation may not corre-
late to implant survival, it can be
an accurate indicator to assess and
compare the healing potential of
the graft.16 Because of the higher
β-TCP content in Osteon II (70%), a
significant amount of graft particles
were resorbed histologically. Thus,
it appeared as though new bone
formation was occurring simultane-
ously with material degradation.
A barrier membrane is used
along with bone graft material to
stabilize the blood clot, exclude
epithelial and connective tissue,
and enable osteogenic cells to pro-
liferate and differentiate.9 Early or
spontaneous membrane exposure
may lead to bacterial colonization,
infection, or membrane degrada-
tion with a poor regenerative out-
come because soft tissue growth
progresses at the rate of 0.5 to
1.0 mm per day and can take 7 to
10 days to granulate.23–27 Cross-
linked collagen membranes remain
intact longer than non–cross-
linked membranes, but the non–
cross-linked or low–cross-linked
collagen membranes may not pro-
vide effective barrier function if ex-
posed prematurely.27
Recent publications support
the idea that the intentional ex-
posure of a resorbable membrane
does not adversely affect the re-
generative outcome.13,28 Primary
flap closure was not necessary to
achieve bone augmentation when
healing was marked by minimal
inflammation and rapid epithelial
migration over the exposed mem-
brane.28 The similarity between the
treatments indicated that the ab-
sence of primary closure did not
affect the percentage of vital bone
regeneration or the difference in
graft stability or osseointegration.
Conclusions
The use of a composite alloplastic
biomaterial in combination with
a collagen membrane allowed
postextraction ridge preservation
as well as sufficient bone qual-
ity and quantity to place dental
implants. Although intentional
membrane exposure could have
resulted in compromised barrier
function to support regeneration,
the sites that healed by second-
ary intention revealed similar clini-
cal, radiographic, and histologic
findings as those that healed by
primary intention. The use of this
alloplastic biomaterial can be con-
sidered as a viable alternative to
the use of autogenous bone or
other bone substitutes.
Acknowledgments
This study was funded by a grant from
Dentium.
77
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3. Nevins M, Camelo M, De Paoli S, et al. A
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4. Araújo M, Linder E, Wennström J, Lindhe
J. The influence of Bio-Oss Collagen on
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8. De Coster P, Browaeys H, De Bruyn H.
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12. Bornstein MM, Bosshardt D, Buser D.
Effect of two different bioabsorbable
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13. Cardaropoli D, Cardaropoli G. Preser-
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14. Hing KA. Bioceramic bone graft substi-
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15. Cordaro L, Bosshardt DD, Palattella P,
Rao W, Serino G, Chiapasco M. Maxillary
sinus grafting with Bio-Oss or Straumann
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sults from a randomized controlled mul-
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16. Froum SJ, Wallace SS, Cho SC, Elian N,
Tarnow DP. Histomorphometric com-
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assessment of vital bone formation. A
pilot study. Int J Periodontics Restorative
Dent 2008;28:273–281.
17. Kim YK, Yun PY, Lim SC, Kim SG, Lee
HJ, Ong JL. Clinical evaluations of OS-
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mater 2008;86:270–277.
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18. Kim YK, Yun PY, Kim SG, Lim SC. Analy-
sis of the healing process in sinus bone
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diol Endod 2009;107:204–211.
19. Frenken JW, Bouwman WF, Braven-
boer N, Zijderveld SA, Schulten EA, ten
Bruggenkate CM. The use of Straumann
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20. Mardas N, Chadha V, Donos N. Alveo-
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regeneration and a synthetic bone sub-
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21. Mardas N, D’Aiuto F, Mezzomo L, Ar-
zoumanidi M, Donos N. Radiographic
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22. Kim DM, Camelo M, Nevins M, Fateh A,
Schupbach P, Nevins M. Alveolar ridge
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ative Dent 2012;32:e204–e209.
23. Engler WO, Ramfjord SP, Hiniker JJ. Heal-
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298–308.
24. Simion M, Baldoni M, Rossi P, Zaffe D. A
comparative study of the effectiveness of
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25. Simion M, Maglione M, Iamoni F, Scar-
ano A, Piattelli A, Salvato A. Bacterial
penetration through Resolut resorbable
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26. Hämmerle CH, Jung RE. Bone augmen-
tation by means of barrier membranes.
Periodontol 2000 2003;33:36–53.
27. Oh TJ, Meraw SJ, Lee EJ, Giannobile
WV, Wang HL. Comparative analysis of
collagen membranes for the treatment
of implant dehiscence defects. Clin Oral
Implants Res 2003;14:80–90.
28. Kim DM, Nevins M, Camelo M, et al. The
feasibility of demineralized bone matrix
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 459

Socket Site Preservation Using Bovine

Bone Mineral With and Without a
Bioresorbable Collagen Membrane

Mally Perelman-Karmon, DMD, MS*/Avital Kozlovsky, DMD** Tooth extraction leads to morpho-
Roman Lilov, DMD***/Zvi Artzi, DMD**** logic changes and resorption of the
alveolar ridge as a result of a lack of
biomechanical forces on the bone.1,2
The purpose of this study was to compare extraction sites augmented with In the immediate postextraction
bovine bone mineral (BBM) with and without resorbable membrane coverage. phase, the fresh extraction socket
BBM particles were grafted in fresh human extraction sockets of 23 patients; possesses a unique wound-healing
in 12 of these patients, a guided tissue regeneration (GTR) membrane was cascade.3–5 Marked dimensional al-
applied. After 9 months of histomorphometric evaluation, cylindric hard terations occur in the edentulous
tissue specimens were obtained. Percent bone area fractions (BAFs) of the
ridge after extraction.1,5,6
crestal, middle, and apical sections from each specimen were calculated using
In the anterior maxilla, there is
the point-counting technique. Changes in values were compared. In sites
consistent bone resorption where
augmented with BBM, the mean BAF ranged from 22.8% (coronal) to 36.3%
(apical) compared to sites augmented with BBM and collagen membrane
the buccal plate is thin. Bone re-
(35.2% [coronal] to 47% [apical]). Comparison between the different depths sorption leads to palatal/lingual
and the two groups showed a distinct increase in BAF from coronal to apical and apical positioning of the alveo-
regions (P < .001). This pattern was observed in both groups (P < .001) and lar crest, since resorption is more
was significantly higher in the group augmented with BBM and collagen prominent in the buccal plate.1,5
membrane (P < .05). In the immediate postextraction phase, BBM as a grafted Thus, preserving the alveolar ridge
biomaterial preserved the socket volume and enabled newly formed bone for and achieving appropriate ridge
future implant site preparation. The amount of the osseous fraction increased dimensions are important7,8 when
with GTR membrane. (Int J Periodontics Restorative Dent 2012;32:459–465.) an implant-supported fixed partial
    *Department of Oral Sciences, School of Dental Medicine, State University of New York,
denture is required.
Buffalo, New York, USA; Formerly, Undergraduate Student, The Maurice and Gabriela The increasing demand for es-
Goldschleger Scool of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. thetic implant dentistry challenges
   **Associate Professor, Department of Periodontology, The Maurice and Gabriela
the clinician. The implant location
Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
  ***Private Practice, Netanya, Israel. should comply with the patient’s
****Associate Professor and Director of Graduate Periodontics, Department of esthetic, functional, and phonetic
Periodontology, The Maurice and Gabriela Goldschleger School of Dental Medicine, needs. Guided tissue regeneration
Tel Aviv University, Tel Aviv, Israel.
(GTR), a biologic principle based on
Correspondence to: Prof Zvi Artzi, School of Dental Medicine, Tel Aviv University, a selective cell population, achieves
Ramat Aviv, Tel Aviv 61390, Israel; email: zviartzi@tau.ac.il. sufficient volume of regenerated

Volume 32, Number 4, 2012

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460
bone.9 Different types of GTR mem-
branes are used with and without a
biomaterial scaffold10,11 to maintain
space over a bony defect (extrac-
tion socket void) and to prevent
undesired cells from migrating into
the defect. The membrane protects
the blood clot formed in the socket.
By protecting and secluding the
socket from the adjacent interfer-
ing connective tissue cells, the
membrane enables and promotes
osteogenic cell migration into the
defect.9
After extraction, the defined
area serves as a wound-healing site.
The healing cascade of the socket
is dominated by coagulum, which
is gradually occupied by granula-
tion tissue followed by a provision-
al matrix (connective tissue).4 One
week postextraction, the socket is
characterized by granulation tissue
consisting of a vascular network, im-
mature connective tissue, osteoid
formation in the apical portion,
and epithelial coverage over the
wound. At 1 month postextrac-
tion, the socket is characterized by
dense connective tissue overlying
the residual sockets and filled with
granulation tissue. A trabecular
pattern of bone starts to emerge.
Epithelium used for wound cover-
age is complete following the se-
quence of bone formation.3,4
In a periodontal deteriorating
situation, when destruction of par-
tial or complete socket walls is evi-
dent, ingrowth of connective tissue
into the extraction site is unavoid-
able, leading to a deficient ridge.
The use of bone substitute, such
as bovine bone mineral (BBM), pre-
The International Journal of Periodontics & Restorative Dentistry
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serves the alveolar ridge by stabiliz-
ing the blood clot, thus maintaining
the volume at the site and simulta-
neously serving as an osteoconduc-
tive guide rail to facilitate continual
bone formation.12–17 BBM applied
in conjunction with a bioresorbable
membrane after a healing period of
9 months has shown complete hori-
zontal bone augmentation.11
While the significant contri-
bution of applying a selective se-
cluded barrier in GTR or guided
bone regeneration (GBR) proce-
dures is evident, the application
of membrane coverage at a fresh
extraction socket while at the same
time obtaining complete soft tis-
sue closure is a challenge. Further-
more, since bone tissue has been
formed with and without the use of
a membrane in animal and human
studies,7,8,12,13,16–18 the indication of
a GBR surgical modality in a unique
healing site (ie, fresh extraction
socket) should be interpreted.
The objective of this study was
to compare the amount of bone
area fraction in fresh extraction
sites using BBM as the grafting
biomaterial, protected or unpro-
tected with a resorbable collagen
membrane, and by using a rotating
pedicle flap or coronally advanced
flap to achieve complete soft tissue
closure.
Method and materials
This study included 23 fresh single-
root extraction sockets in 23
healthy patients (16 women, 7 men)
with no systemic diseases. Patients
ranged from 26 to 68 years of age
and were nonsmokers. The proce-
dure was explained, and patients
signed consent forms. The study
was in accordance with the Helsinki
Declaration.
Before extraction, clinical
(probing) and radiographic param-
eters were collected (Figs 1a and
1b). Sites exhibiting severe to com-
plete socket wall destruction were
excluded.
Extracted teeth included max-
illary incisors (n = 10) and maxil-
lary (n = 8) and mandibular (n = 5)
single-root premolars. At least 50%
of sockets were partially resorbed/
destructed at one to two walls, but
not circumferentially so that the
inclusion criteria of containing the
grafted particles and supporting
the applied over-latticed resorb-
able membrane could be met.
Immediately following extraction,
BBM particles (250 to 1,000 µm;
Bio-Oss, Geistlich) were placed to
fill the site completely (Fig 1c). The
decision to use sites with or with-
out the application of a resorbable
membrane was determined ran-
domly by flipping a coin before ex-
traction. A double layer of collagen
membrane (Bio-Gide, Geistlich)
was applied in 11 sites (Fig 1d). The
membrane covered the entire site
and was secured labially and lin-
gually under soft tissue flaps.
In the maxilla, complete soft
tissue closure was obtained using a
rotating pedicle flap from the pala-
tal side. Advanced coronal, buccal,
and lingual flaps ensured soft tissue
closure in mandibular premolars.
The distal superficial end of the

pedicle flap was de-epithelialized
and sutured (4-0 Vicryl, Ethicon) to
the inner layer of the buccal flap
to obtain complete soft tissue clo-
sure over the membrane-protected
grafted site (Fig 1e). The same soft
tissue management was performed
in the unprotected group (n = 13)
but without applying the GTR
membrane. The exposed palatal
area was left for secondary healing.
Patients were prescribed anal-
gesics (naproxen 275 mg; Narocin,
Teva Pharmaceutical) and instruct-
ed to rinse with 0.2% chlorhexidine
gluconate (Tarodent, Taro Pharma-
ceutical) twice a day for 30 seconds
for 2 weeks. Complete soft tissue
healing was observed at 1 month
postgrafting (Fig 1f). Computed to-
mography scans were taken to plan
the future implant prosthetic recon-
struction (Fig 1g).
Since BBM is a slow biodegrad-
able material,17 an extended heal-
ing phase was allowed for possible
interpretation between membrane-
protected and unprotected healing
sites. At 9 months, at implant place-
ment, a midcrestal incision was
made to expose the grafted site
(Fig 1h). At this stage, instead of
the usual sequence of step-up drill-
ing for implant site preparation, a
2.5-mm–internal diameter trephine
bur was applied to harvest a cylin-
dric hard tissue core approximately
8 mm in length. The apical end of
each specimen was marked for ori-
entation to identify the peripheral
versus deep ends.
Specimens (n = 23) were fixed
in 10% neutral buffered formalin
for 1 week and then decalcified
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461
with 5% formic acid for 2 weeks.
The decalcified cylindric speci-
mens were embedded in paraffin
and transversely cut into serial sec-
tions 5-µm wide using a microtome
(Leica RM 2245, Leica Microsys-
tems). Each core was cut uniform-
ly from the peripheral to deeper
regions. Slides were stained with
hematoxylin-eosin. From each tis-
sue cylinder, six representative cuts
undamaged during microtome cut-
ting were selected for morphomet-
ric analysis: two from the coronal
portion (1 to 2 mm), two from the
middle core, and two from the apical
end (1 to 2 mm). Data from each pair
were averaged and used as such.
Histomorphometry
In each section, bone area fraction
at membrane-protected (m-BAF)
and biomaterial-only (BAF) grafted
sites was measured using an adap-
tation of the point-counting proce-
dure.12,17,19–22 Briefly, each section
was examined in a projection mi-
croscope (Visopan, Reichart, Leica)
at 20× magnification. A 64-square
(1.5 × 1.5 cm) graticule was su-
perimposed on the screen for the
point-counting calculation. Bone
tissue was recorded whenever the
graticule center (marked with “+”)
hit the bone tissue.12,21,22 The sum
(Pi) of the points overlying the bone
tissue was calculated. Percentage
of bone tissue was evaluated as a
portion of the entire section area
(Pi / Σi), where Σi represents the to-
tal number of points superimposed
on each section.
Volume 32, Number 4, 2012
462

Fig 1a (left)    Clinical appearance of a

maxillary right central incisor. The marginal
gingiva was inflamed, and the tooth had
migrated slightly labially and mesially be-
cause of the periodontal condition.

Fig 1b (right)    Periapical radiograph of the

maxillary central incisor. Severe periodontal
destruction is evident.

Fig 1c    Fresh extraction socket filled with Fig 1d    Bioresorbable membrane applied Fig 1e    Complete soft tissue closure was
BBM particles. to cover the augmented socket. obtained using a pedicle palatal rotated flap.

Fig 1f    At 1 month, soft tissue healing was Fig 1g    Buccolingual computed tomogra- Fig 1h    At reentry, a wide buccolingual os-
evident. phy section of the grafted extraction site. seous table had been established.

All measurements were taken measurements and the coefficient

by the same investigator. To de- of variation (CV) for each parameter,
termine the reproducibility of the 10 randomly selected slides were

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 463

Fig 2a (left)    Typical coronal decalcified

section cut. An abundance of soft tissue
(ST) and grafted particles (P) surrounded
by newly formed bone (B) can be seen
B
(hematoxylin-eosin, original magnification B
ST ×25).

B B
P Fig 2b (right)    Apical section with a high B
P
P percentage of bone area fraction (B)
(hematoxylin-eosin, original magnification
B
×25).
ST

Fig 3    Mean BAF at the crestal, middle, and apical regions of the
†
membrane-protected and unprotected extraction sites augmented by †
70 † Membrane-protected
BBM particles. **P < .05; ***P < .001, †P < .001 (within-subject data). †

60 *** Unproteced
**
50

Mean BAF (%)

**
40
30
20
10
0
Crestal Middle Apical

measured 5 times, not consecu-
tively, without reference to the pre-
vious data. The mean CV of bone
(2.2%), biomaterial particle (2%), and
remaining concavity area fractions
(1.8%) indicated that these measure-
ments were highly reproducible.
During measurements, the in-
vestigator was masked to the type of
site with respect to whether the mea-
surement was conducted on protect-
ed or unprotected membrane sites;
the same applied for its depth.
Repeated-measures analysis
of variance was used. The within-
subject factor was depth, and the
between-subject factor was mem-
brane coverage. Values were con-
sidered significant at P < .05.
Results
All patients were observed fre-
quently, and postoperative heal-
ing was immaculate. Histologic
examination revealed that all cores
harbored an abundance of BBM
particles surrounded by newly
formed bone. In the membrane-
protected group, total bone frac-
tion ranged from 23% to 72%
(mean, 40.8% ± 10.61%) (Figs 2a
and 2b). m-BAF ranged from 24.0%
to 52.5% (mean, 35.2% ± 9.18%),
24.5% to 59.5% (mean, 40.2%
± 10.74%), and 23.0% to 72.0%
(mean, 46.95% ± 12.83%) at the
crestal, middle, and apical regions,
respectively. In the unprotected
group, total BAF ranged from 15%
to 54% (mean, 29.7% ± 7.21%).
BAF ranged from 15.0% to 33.0%
(mean, 22.8% ± 5.11%), 16.5% to
47.5% (mean, 29.9% ± 8.98%), and
21.5% to 54.0% (mean, 36.3% ±
11.3%) at the crestal, middle, and
apical regions, respectively.
Mean m-BAF was significantly
greater than BAF at all respective
depths (P < .05). In both groups
(m-BAF and BAF), a gradual in-
crease in bone area fraction was
observed from the coronal to apical
areas. Within each type, the bone
area fraction in the apical region was
statistically greater than that in the
middle and crestal areas (P < .001)
(Fig 3).

Volume 32, Number 4, 2012

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464
Discussion
BBM, which has been used for over
20 years, has proven to be a suitable
biomaterial in augmentation proce-
dures. Clinical and histologic stud-
ies have shown the efficacy of this
osteoconductive material.11,18,23,24
A high osteoconductive property
by BBM has also been shown in a
recent comparative study in human
extraction sockets.15
BBM particles have been
shown to be well integrated with
regenerated bone in extraction
and alveolar ridge deficiency sites
in animal16,23,25 and human clinical
studies,11,18,24,26 as well as in mor-
phometric studies.12,22 In a human
study,27 excellent osseointegration
and crestal bone level maintenance
were shown when implant place-
ment was combined with bone
augmentation using BBM as the
grafting biomaterial.
In the current study, all 23 con-
secutive patients showed primary
soft tissue closure and excellent
healing whether GTR membrane
coverage was applied or not.
However, the point-counting his-
tomorphometry disclosed a distin-
guishable observation. Regardless
of the depth of the examined his-
tologic section, a membrane-
protected grafted socket site
showed greater newly formed
bone when compared with unpro-
tected grafted sites. It should be
considered that a membrane-pro-
tected site is advantageous since
the GTR membrane confines the
grafted particles during the first
period of healing and stabilizes the
The International Journal of Periodontics & Restorative Dentistry
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
entire site, in addition to its bio- ed. In a computed tomography–
logic contributions. In unprotected derived bone density study in
sites, some particulate biomate- dogs,29 similar findings were shown
rial would be lost or reside in the with regard to the contribution
overlying soft tissue. Nevertheless, of the GTR modality. Moreover,
in both sites, BBM particles were wound site stability and undesired
surrounded by newly formed bone, micromovement,30 which can occur
and all sites exhibited clinical hard in this region, might influence the
tissue formation, which was suit- remodeling process.
able for implant site preparation.
The slow resorption rate of
BBM does not inhibit continuous Conclusions
bone formation. On the contrary, it
enhances it progressively.17 BBM, as a grafted biomaterial in
In unprotected grafted human fresh extraction sockets, preserved
sockets,12,26 BAF increases when its volume and enabled newly
approaching the apical area. In- formed bone for future implant
trabony defects healed with BBM site preparation. The application of
alone or with BBM and a resorb- GBR increased the osseous fraction.
able membrane. It has been shown
that the amount of bone regenera-
tion is further enhanced with the Acknowledgments
latter.28
The authors thank Mrs Ilana Gelerntner for
Caution should be taken when
the statistical analysis and Ms Rita Lazar for
internalizing the morphometric
editorial assistance.
data if the examined sites are nei-
ther identical nor standardized
before grafting. However, the re-
peated outcomes at the 12 versus
11 consecutively examined sockets
should strengthen the findings.
In this study, the least BAF was
found in the crestal zone, regardless
of whether the site was membrane-
protected. This could be explained
by the distance between the socket
walls.12 In the extraction site, the
distance between the socket walls
is reduced toward the apical region.
Thus, this is an amply nourished
site.
The fact that a membrane-pro-
tected socket site showed greater
newly formed bone was anticipat-

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Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

Ridge Preservation Comparing a Socket Allograft Alone to a

Socket Allograft Plus a Facial Overlay Xenograft: A Clinical and
Histologic Study in Humans
Evmenios Poulias, DDS, MS*, Henry Greenwell, DMD, MSD†,  Margaret Hill, DMD‡,  
Dean Morton, DMD, MS§, Ricardo Vidal, DDS, MS‖, Brian Shumway, DMD, MS¶,
Thomas L. Peterson, DDS, MS#

Private Practice, Athens, Greece.

Professor, Director of Graduate Periodontics, University of Louisville, Louisville, KY.

Associate Professor, Assoc Dean Postdoctoral Education, University of Louisville,

Louisville, KY.

Professor, Chair, Dept of Oral Health & Rehabilitation, University of Louisville,

Louisville, KY.

Assistant Professor, Periodontics, University of Louisville, Louisville, KY.

Assistant Professor, Oral Pathology, University of Louisville, Louisville, KY.

Private Practice, Macon, Georgia.

Background. Previous studies of ridge preservation showed a loss of about 18% or 1.5 mm of
crestal ridge width in spite of treatment. The primary aim of this randomized, controlled, blinded clinical
trial was to compare a socket graft to the same treatment plus a buccal overlay graft, both with a polylactide
membrane, to determine if loss of ridge width can be prevented by use of an overlay graft.
Methods. Twelve positive control patients received an intrasocket mineralized cancellous
allograft (Socket group) while twelve test patients received the same socket graft plus buccal overlay
cancellous xenograft (Overlay group). Horizontal ridge dimensions were measured with a digital caliper
and vertical ridge changes were measured from a stent. Prior to implant placement at 4 months a trephine
core was obtained for histologic analysis.
Results. The mean horizontal ridge width at the crest for the Socket group decreased from 8.7 ±
1.0 mm to 7.1 ± 1.5 mm for a mean loss of 1.6 ± 0.8 mm (p < 0.05) while the Overlay group decreased
from 8.4 ± 1.4 mm to 8.1 ± 1.4 mm for a mean loss of 0.3 ± 0.9 mm (p > 0.05). The Overlay group was
significantly different from the Socket group (p < 0.05). Histologic analysis revealed that the Socket group
had 35 ± 16% vital bone while the Overlay group had 40 ± 16% (p > 0.05).
Conclusions. The Overlay treatment significantly prevented loss of ridge width and preserved or
augmented the buccal contour. The Socket and Overlay groups healed with a high percentage of vital bone.

KEY WORDS:
allograft; xenograft; grafting, bone; socket graft; bone regeneration.
Following extraction there is substantial resorption of the alveolar ridge resulting
in compromised ridge dimensions. Araujo et al. have shown that bone resorption is most
pronounced on the buccal.1-5 This is due to loss of bundle bone that results in the loss of
a portion of the buccal plate. When human extraction alone studies are reviewed as a

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Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

group they show that, on average, approximately 3.7 mm or 45% of horizontal ridge
width is lost within a 4 to 6 month period.6-14 Ridge height, on the other hand, is less
affected and on average only about 1.6 mm is lost.6-14
In an effort to reduce post-extraction bone loss clinicians have performed what is
known as a ridge preservation procedure. This treatment utilizes an osseous graft and/or
a barrier membrane to manage the extraction socket. The goal of this procedure is to
ensure that adequate ridge width is preserved to allow implant placement totally within
bone and to avoid complications such as implant dehiscence and fenestration. In spite of
these efforts, most studies of ridge preservation show that there is still some loss of
horizontal ridge width that can lead to a concave buccal contour and may lead to a
dehiscence or fenestration at the time of implant placement. Ridge preservation studies
as a group show that, on average, about 1.5 mm or 18% of horizontal ridge width is lost.6-
9,11-32
Ridge height is minimally affected and, on average, less than about 0.5 mm of
height is lost.6-15,17,18,20,21,23,24,27,29-33
Wang et al. have described a "sandwich" technique of layered osseous grafting
that utilizes an outer layer that resists resorption and will remain in place for an extended
or indefinite period.34 The inner layer, on the other hand, is resorbed and replaced more
quickly by newly formed vital bone. These principles will be utilized in this study.
Bovine xenograft has been reported to resorb very slowly and become fibrous
encapsulated while cancellous allograft is resorbed and replaced more quickly through a
process known as creeping substitution.18,34-40 These two materials fulfill the principles
proposed by Wang et al.34 Therefore the cancellous allograft was chosen as a rapidly
resorbing socket graft while the bovine xenograft was chosen as a buccal overlay to resist
resorption and preserve the buccal contour. The specific aim of this study was to
determine if ridge preservation treatment can be performed in a manner that will prevent
the loss of crestal ridge width thereby preserving the original buccal contour. Comparing
a socket graft alone to a socket graft plus a facial overlay will provide a valid test of the
hypothesis that loss of crestal ridge width can be prevented when a slowly resorbing
facial overlay graft is utilized.

METHODS
Study Design
A total of 24 patients participated in this 4-month randomized, controlled, blinded clinical
study of ridge preservation in sequentially entered single extraction sites of nonmolar
teeth to be replaced by a dental implant. Twelve positive control patients were randomly
selected, using a coin toss, to receive ridge preservation treatment with an intrasocket,
mineralized, cancellous, particulate allograft (500-800 µm, Socket group).* The twelve
test patients received the same intrasocket allograft plus a facial overlay with a
mineralized, cancellous, particulate bovine xenograft (250-1000 µm, Overlay group).† A
bioresorbable polylactide membrane was used to cover the osseous graft in both groups.‡
Four months after the grafting procedure the implant placement surgery was performed
and a trephine core was removed from the osteotomy site for histologic analysis. All
surgical procedures were completed by one operator (EP) under the direction of one
mentor (HG). The surgeon was trained in the procedures until considered proficient. All

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Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

blinded measurements were performed by one blinded examiner (TP), who was unaware
of the treatment assignment at all time points. The mentor performed the coin toss after
flap reflection and immediately prior to graft placement and verified the measurements
taken by the blinded examiner. All patients signed an informed consent approved by the
University of Louisville Institutional Review Board in August 2011, when this study
11.0352 was also approved. This study was conducted in accordance with the Helsinki
Declaration of 1975, as revised in 2000. The study was conducted between September
2011 and July 2012 in the Graduate Periodontics clinic at the University of Louisville.

Outcome Variables
The primary outcome variable was crestal horizontal ridge width and the power analysis
was based on this variable. Other variables evaluated included vertical ridge dimension
change and histologic assessment of vital bone, non-vital bone and trabecular space.

Inclusion/Exclusion Criteria
Subjects met the eligibility criteria if they were at least 18 years of age and had one
nonmolar tooth requiring extraction that would be replaced by a dental implant.
Extraction sites were bordered by at least one tooth. Exclusion criteria included: 1)
debilitating systemic diseases, or diseases that have a clinically significant effect on the
periodontium; 2) molar extraction sites; 3) presence of or history of osteonecrosis of the
jaws; 4) history of IV bisphosphonate treatment; 5) history of oral bisphosphonate
treatment for more than three years; 6) pregnancy or lactation; 7) known allergy to any
material or medication used in the study; 8) required antibiotic prophylaxis; 9) previous
head and neck radiation therapy; 10) history of chemotherapy in the last 12 months; 11)
long term steroid or non-steroidal anti-inflammatory drug therapy; or 12) failure to sign
an informed consent approved by the Human Studies Committee. Patients were excluded
post-treatment if they developed infection or had an adverse reaction to any of the
materials used in the study.

Clinical and Radiographic Parameters

Each patient received a diagnostic work-up that included standardized periapical
radiographs, study casts, clinical photographs, and a full periodontal examination.
Radiographic and study cast data will not be presented or discussed. Customized occlusal
stents were fabricated on the study casts to serve as fixed reference guides for the vertical
measurements.9
Clinical parameters on adjacent teeth assessed at baseline and at the 4-month re-
entry included Plaque Index, Gingival Index, bleeding on probing (dichotomous),
keratinized tissue width, recession, probing depth, clinical attachment level, CEJ to
alveolar crest distance, and tooth mobility.41,42 Horizontal ridge width was recorded with
a modified digital caliper measuring to the nearest 10-2 at the mid-socket crestal level and
5 mm apically. Vertical distance from the acrylic stent to the alveolar crest was measured
mesially, mid-socket and distally on all buccal, occlusal and lingual surfaces using a 15
mm North Carolina periodontal probe.9

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Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

Surgical Treatment
Full thickness flaps were elevated to expose both the facial and the palatal/lingual aspects
of the alveolar ridge. The flaps were extended one tooth mesial and distal to the
preservation site on the buccal and vertical incisions were placed on the buccal and
palatal. Papillae preservation incisions were used to keep the papilla intact.43 The teeth
were extracted as atraumatically as possible using periotomes, elevators and forceps.
After the extraction, the socket was carefully curetted to remove all soft tissue.
The allograft and xenograft materials were hydrated in a 50 mg/ml solution of
tetracycline. The socket allograft was placed to the level of the alveolar crest and the
facial overlay xenograft was placed over the buccal wall of the extraction socket from the
alveolar crest to about 12 mm apical and was extended about half a tooth to the mesial
and distal. The polylactide barrier membrane was trimmed to completely cover the socket
and extended at least 3 mm past the alveolar crest and at least 3 mm past the lateral and
apical borders of the facial xenograft. The membrane overlying the central portion of the
socket was left exposed. Flaps were replaced or slightly coronally positioned. If needed,
an apical periosteal split was performed to permit adequate flap release for tension-free
closure. Flaps were sutured with a 4-0 polytetrafluoroethylene suture.§ Compression of
the facial overlay graft was avoided by ensuring that flap closure was tension free.
Patients were given a post-surgical regimen consisting of 375 mg naproxen (twice a day
for one week), 50 mg doxycycline hyclate (once a day for two weeks) and narcotic
analgesics as needed. Patients were seen every two weeks until soft tissue closure was
complete and then monthly until the 4-month implant placement.

Implant Placement
Full-thickness flaps were elevated on the buccal and palatal/lingual using a papilla
preservation technique. All baseline clinical measurements were repeated and a
standardized radiograph was taken. A 2.7 x 6.0 mm trephine was used with copious
chilled saline irrigation to remove a core from the osteotomy site prior to implant
placement.║ The core was subsequently placed in 10% buffered formalin for histologic
processing. A dental implant was placed and flaps were replaced and sutured with 4-0
silk or the polytetrafluoroethylene sutures described previously.

Contour Data
Pre- and post-treatment unlabelled occlusal clinical photographs were compared to
determine the initial and final buccal contour. Each contour was subjectively categorized
as a concave, flat or convex contour. Two blinded examiners (HG, EP) had to agree on
each contour categorization. Since this was a subjective evaluation it was considered
important to use two examiners. Subsequently the pre-and post-treatment categories
were compared to determine if there was a loss, no change or a gain in terms of contour.

Tooth Type Data

Data from previous studies of ridge preservation at this institution (this study, 2
publications, and 5 Master's theses) that were measured using the same technique as in
this study were grouped according to tooth type to determine initial and final ridge

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Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

dimensions, the change and the percent change.9,18 Data for this analysis came from sites
that received socket treatment alone without an overlay graft.

Histologic Analysis
Trephine cores (2.7 X 6 mm) were decalcified and 12-15 step serial sections were taken
from the center of each longitudinally sectioned core. The sections were stained with
hematoxylin and eosin. Ten slides per patient were prepared, each containing at least 4
sections. Six randomly selected fields, 1 per section if possible, were used to obtain
percent cellular bone, acellular bone, and trabecular space using an American Optics light
microscope at 150x with a 10x objective and 15x reticle eyepieces.9

Statistical Methods
Means and standard deviations were calculated for all parameters. A paired t-test was
used to evaluate the statistical significance of the differences between initial and final
data. An unpaired t-test was used to evaluate statistical differences between the test and
control groups. The sample size of 11 per group gave 80% statistical power to detect a
difference of 1 mm between groups for crestal ridge width. Power calculations were
based on data from previous studies.9,18

RESULTS
A total of 24 patients were entered in this study. For the Socket group 8 females
and 4 males with a mean age of 52 ± 16, ranging from 26 to 77 years, were enrolled
while 5 females and 7 males with a mean age of 58 ± 11, ranging from 38 to 71 years,
were enrolled in the Overlay group. All sites were bordered by at least one tooth mesially
or distally. The Socket group consisted of 1 maxillary incisor, 2 maxillary canines, 8
maxillary premolars, and 1 mandibular premolar. The Overlay group consisted of 5
maxillary incisors, 1 maxillary canine, and 6 maxillary premolars. There were 2 smokers
enrolled in the Socket group and 2 in the Overlay group. The reason for extraction in the
Socket group was 9 due to caries, 2 due to root fracture and 1 due to root resorption; in
the Overlay group 6 were extracted due to caries, 5 due to root fracture and 1 due to root
resorption. There were no adverse events that occurred due to this treatment.
All 24 patients completed the study, however, one patient in the Overlay group
(1/12) was excluded following data analysis. This patient had a buccal wall missing at the
time of extraction and the amount of ridge width gain was large. This represented an
outlier value that skewed the data and did not represent what typically happens following
a ridge preservation procedure.

Clinical Indices
Plaque index, gingival index and bleeding on probing had low initial values for both
groups, about 0.1 ± 0.1, and were virtually unchanged at the 4-month implant placement
visit. There were no significant differences between initial and final values or between
the test and the control groups (p > 0.05).

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Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

Horizontal Ridge Width Changes

The Socket group had a statistically significant mean loss of crestal width of 1.6 ± 0.8
mm (p < 0.05) while the Overlay group had mean loss of only 0.3 ± 0.9 mm, which was
not statistically significant (p > 0.05, Table 1). The difference between the 2 groups was
statistically significant (p < 0.05). At 5 mm apical to the crest the Socket group had a
significant mean loss of 0.8 ± 0.5 mm (p < 0.05) while the Overlay showed a statistically
significant mean gain of 0.5 ± 0.6 mm (p < 0.05). The difference between the test and
control groups was statistically significant (p < 0.05, Table 1).

Vertical Ridge Height Change

On the mid-buccal the Socket group gained a mean of 0.5 ± 2.9 mm while the Overlay
group gained 0.3 ± 2.6 mm, which was not statistically significant for either group (p >
0.05). The difference between the test and control groups was not statistically significant
(p > 0.05, Table 2). Data and statistical significance for the mid-lingual, the mesial and
the distal portion of the socket are shown in Table 2.

CEJ to Osseous Crest Changes

Mesial CEJ to osseous crest distance for the Socket group showed a significant mean loss
of 0.3 ± 0.3 mm (p < 0.05), while the Overlay group also had a significant mean loss of
0.5 ± 0.4 mm (p < 0.05). Distal CEJ to osseous crest distance for the Socket group
showed a significant mean loss of 0.5 ± 0.7 mm (p < 0.05), while the Overlay group had a
mean loss of 0.3 ± 0.5 mm, which was not statistically significant (p > 0.05). There were
no statistically significant differences between groups for either mesial or distal sites.

Buccal Contour
For the Socket group 5 sites ended with a concave contour while 7 were flat. For the
Overlay group 4 sites ended with a flat contour while 7 were convex. In the Socket group
this represented a loss of contour for 9 sites and no change for 3. For the Overlay group 4
sites had no change in contour while 7 showed a gain.

Histologic evaluation
The Socket group healed with a mean of 35 ± 16% vital bone, 21 ± 13% non-vital bone
and 44 ± 9% trabecular space, while the Overlay group healed with a mean of 40 ± 16%
vital bone, 17 ± 11% non-vital bone, and 43 ± 12% trabecular space. There were no
statistically significant differences between the Socket and Overlay groups for vital or
non-vital bone or trabecular space (p > 0.05, Table 3).

DISCUSSION
The primary aim of this 4-month randomized, controlled, blinded clinical study
was to test the hypothesis that crestal ridge width could be preserved when a facial
overlay xenograft that resists resorption was used. It was demonstrated that crestal ridge
width can be almost entirely preserved when a slowly resorbing buccal overlay xenograft
is used therfore the hypothesis should be accepted. This is in contrast to previous ridge

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Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

preservation studies where about 18% of crestal ridge width was lost.6-9,11-32 Furthermore
at 5 mm apical to the crest there was a gain of 0.5 mm of ridge width. This supports the
concept proposed by Wang et al. that a slowly resorbing outer layer of grafting material
may resist resorption and have a beneficial effect on the final result.34 They also
proposed that a rapidly resorbing inner graft layer is beneficial since it will be replaced
by newly formed vital bone. In this study the socket graft was mineralized particulate
cancellous allograft that healed with a high percentage of vital bone present. This means
that at the site of implant placement, the previous socket area, there was a high
percentage of vital bone present to promote osseointegration.
One question that needs to be considered is when an overlay graft is indicated. It
adds time and expense to the ridge preservation procedure so there should be a
compelling reason to complicate the grafting procedure by using an additional graft
material. Data from ridge preservation sites from this study and other studies at the
University of Louisville (2 publications and 5 Master's theses) indicate that maxillary
sites tend to have more resorption than mandibular sites and that maxillary anterior sites
tend to have the highest percentage of lost ridge width when compared to other sites
(Table 4).9,18 Another consideration in maxillary anterior sites is that there is often a
significant undercut or ridge concavity that extends corono-apically. This phenomenon
can lead to a fenestration at the time of implant placement while narrow crestal ridge
width may lead to dehiscence.
According to Woelfel's Dental Anatomy textbook maxillary incisors are about 6.0
mm in buccal-palatal width at the cervix, canines are about 7.5, premolars are about 8.1
and molars are about 10.7 mm.44 Mandibular dimensions are about 5.5 mm for incisors,
7.5 for canines, 7.1 for premolars and 8.9 mm for molars. This means that the smaller the
initial ridge (socket) dimension the more likely that the site will need an overlay graft.
Thus incisor, canine and premolar sites are the most likely candidates for an overlay
graft, especially if a significant undercut is present. Mandibular incisor sites are the
narrowest, however, the greatest percent resorption occurs in the maxilla (Table 4). Thus
initial site width, likely percent resorption, and depth of the undercut are all factors that
may influence the decision to use an overlay graft. Site analysis following tooth
extraction utilizing these factors will lead to the best treatment decision.
Another advantage of the bovine xenograft is preservation of the original buccal
contour in a mesio-distal direction. Without an overlay graft this contour is likely to
become concave (Figure 1a) while use of the overlay most often results in a convex
(Figure 1b) or at least a flat contour. In this study all pre- and post-op contour clinical
photos were evaluated and scored for initial and final contour. This demonstrated that the
overlay graft preserved or gained ridge contour, which is an esthetic advantage, while the
Socket group lost contour at most sites.
If the goal of implant surgery is to place the implant totally within vital bone with
no dehiscence or fenestration defects then the selection of a ridge preservation procedure
can be an important decision. Development of an adequate ridge is also important if
implant placement will be done using a flapless procedure, which may have esthetic
advantages for the soft tissue and papillae. Another advantage of adequate ridge width is
that following implant placement having 2 mm of bone buccal to the implant will help
prevent soft tissue recession.45,46 Inadequate crestal ridge width, on the other hand, could

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Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

lead to implant dehiscence and potentially peri-implantitis. While additional grafting can
be performed at the time of implant placement, the goal of the initial grafting procedure
should be to establish adequate ridge dimensions so that no further grafting will be
necessary at the time of implant placement. Therefore the overlay graft may be useful in
successful development of adequate ridge width.
The most difficult aspect of the ridge preservation procedure is maintaining or
gaining crestal ridge width. This means graft compression at the crest must be avoided
and graft displacement either apically or laterally must be prevented. This was
accomplished in this study by extending the flap one tooth mesial and distal to the
extraction site. For the papilla preservation flap, the papillary incision was similar to that
recommended by Bernimoulin et al. for a coronally positioned flap.43 Thus a new papilla
tip was created about 3 mm apical to the existing papilla tip. The existing papilla was
then de-epithelialized and the new papilla tip was positioned coronally to the tip of the
existing papilla. An apical periosteal release gave adequate flap mobility to allow
coronal positioning and to accommodate a thick layer of xenograft.
About 3 to 4 mm of xenograft thickness was placed as a buccal overlay, and
perhaps more thickness was achieved apically. Also the graft was extended mesially and
distally to the mid-root prominence of the adjacent teeth. This helped prevent apical and
lateral displacement of the graft. Crestally the flap was closed with minimal tension to
avoid graft compression. Another factor may have been the slight rigidity of the
polylactide membrane, which also helped resist crestal compression.
Two previous studies tested the effect of an overlay graft.16,17 One showed a gain
and one showed a slight loss of ridge width. Simon et al. showed a gain and the overlay
graft was applied to the buccal, the crest and to the palatal/lingual.16 The gain was about
1.1 mm of ridge width, however, the measurement was at 3 mm apical to the crest rather
than at the crest as was done in this study. Also different graft and membrane materials
were used. Thus, although the data are not directly comparable, the present study
confirms that the overlay graft approach can have a beneficial effect. Zubillaga et al. was
performed in a similar fashion to Simon et al. but they used different graft materials,
which resulted in a slight loss of about 0.5 mm of ridge width at 3 mm apical to the
crest.17
Histologic analysis showed a high percentage of vital bone in the mid-socket area
where the trephine core was harvested, which is where the cancellous allograft was
placed (Table 3). This indicated that the goal of the Wang et al. layered graft had been
achieved and that the implant would be placed in an area with a high percentage of vital
bone.34 None of the histologic sections showed any signs of the xenograft. This
indicates that it served to maintain and gain space and did not collapse into the socket
area as the bundle bone and the allograft resorbed. The cancellous allograft used
followed the healing pattern described by Burchardt et al. for cancellous autograft.37
Figure 2a-c demonstrates the vital bone, osteoblasts and appositional bone growth they
reported as prominent features of cancellous graft healing.
A resorbable polylactide barrier membrane was used to contain the graft particles
and to fulfill the objectives of guided bone regeneration. Thus the membrane was used to
promote more rapid bone formation by preventing the ingrowth of connective tissue or

8
Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

epithelium due to its barrier function. Since the primary objective of this study was to
compare two grafting techniques the same membrane was used at all sites. The
membrane was easy to use and all sites healed without any membrane associated
complications. The portion of the membrane overlying the socket opening was left
exposed and this resorbed by 6 to 8 weeks. Soft tissue had formed in this area by the
time of membrane resorption and thus the graft was completely covered by either
membrane or soft tissue at all times.
While there are many different ridge preservation procedures to choose from, the
buccal overlay approach using a xenograft appears to be a viable option. When site
analysis is used it can be determined whether the overlay or the intrasocket approach is
the most appropriate treatment. The choice of graft materials to accomplish different
purposes within the same graft as proposed by Wang et al. appears to be a valid and
useful concept in implant site development surgery.34 Preservation of the original buccal
contour is an esthetic advantage of this periodontal plastic surgery procedure.

Conflict of Interest Statement:

This study was performed in Graduate Periodontics, University of Louisville without any grant funding.
No commercial interests were involved and the authors report no conflict of interest. Dr. Greenwell has
previously performed research for Sunstar Americas. Their membranes were used in this study but they
supplied no funding or materials for this study.

Sources of support:
This study received no support from outside sources. Drs. Poulias, Greenwell, Hill, Morton, Vidal,
Shumway and Peterson report no financial relationships related to any products involved in this study. Dr.
Greenwell performs research for Sunstar Americas, Chicago, IL.

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26. Gholami GA, Najafi B, Mashhadiabbas F, Goetz W, Najafi S. Clinical, histologic and
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44. Scheid RC, Weiss G. Woelfel's Dental Anatomy. Eighth Edition. Philadelphia: Lippincott Williams &
Wilkins; 2012:65-162.
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Address correspondence and requests for reprints to Dr. Henry Greenwell, Graduate
Periodontics, School of Dentistry, University of Louisville, Louisville, KY 40292
(address is complete); Phone 502 852-6928; Fax 502 852-1317; email
henry.greenwell@louisville.edu
Submitted September 26, 2012; accepted for publication December 12, 2012.

Figure 1a.
Concave ridge contour associated with intrasocket graft alone treatment at 4 months associated with the
extraction of tooth #5.

Figure 1b.
Convex ridge contour associated with the overlay graft treatment at 4 months associated with the
extraction of tooth #4.

Figure 2a.
Vital bone harvested from the cancellous allograft site, which contains osteocytes in the lacunae. 100X.

Figure 2b.
Osteoblasts lined up along the surface of vital bone. Arrows indicate osteoblasts. 200X.

Figure 2c.
Appositional bone growth with vital bone growing on non-vital residual graft particles. Arrows indicate
vital bone that has formed on non-vital bone. 200X.
Table 1
Horizontal Ridge Width for Intrasocket and Overlay Sites Mean ± sd in mm
Group Initial Final Change % Change Range
Intrasocket at Crest 8.7 ± 1.0 7.1 ± 1.5 -1.6 ± 0.8* -19 ± 11 -3.4 to - 0.5
Overlay at Crest 8.4 ± 1.4 8.1 ± 1.4 -0.3 ± 0.9† -3 ± 10 -2.0 to 0.9

Intrasocket at 5 mm 9.1 ± 0.9 8.4 ± 0.9 -0.8 ± 0.5* -8 ± 5 -1.8 to 0.0

Overlay at 5 mm 8.6 ± 1.9 9.1 ± 2.0 0.5 ± 0.6*† 7±8 -0.8 to 1.5

* = p < 0.05 between initial and 4-month values

† = p < 0.05 between overlay and intrasocket groups

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Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

Table 2
Vertical Ridge Height Change for Intrasocket and Overlay Sites Mean ± sd in mm
Location Intrasocket Overlay Intrasocket Overlay

Mean Change ± sd in mm Range in mm

Mid-Buccal 0.5 ± 2.9 0.3 ± 2.6 -2.0 to 8.0 -3.0 to 5.0

Mid-Lingual -0.4 ± 0.6 -0.5 ± 0.7* -1.5 to 0.5 -1.5 to 0.5

Mesial -0.5 ± 0.4* -0.6 ± 0.4* -1.2 to 0.0 -1.1 to 0.0

Distal -0.8 ± 0.3* -0.4 ± 0.4*† -1.3 to -0.1 -1.0 to 0.0

* = p < 0.05 between initial and 4-month values

† = p < 0.05 between overlay and intrasocket groups
Table 3
Histologic Data at Implant Placement for Intrasocket and Overlay Sites Mean ± sd
Group Time n % Vital % Non-vital % Trabecular

Intrasocket 4 month 12 35 ± 16 21 ± 13 44 ± 9

Overlay 4 month 11 40 ± 16 17 ± 11 43 ± 12

Table 4
Ridge Dimensions by Tooth Type Mean ± sd in mm
Tooth Type n Initial Final Change % Change

Maxillary Incisor 38 7.7 ± 1.0 5.8 ± 1.4 -1.9 ± 1.2 -24 ± 15

Mandibular Incisor 2 5.9 ± 0.2 5.1 ± 0.0 -0.9 ± 0.2 -15 ± 3
Maxillary Canine 8 8.8 ± 0.7 6.4 ± 2.1 -2.4 ± 2.0 -28 ± 22
Mandibular Canine 3 7.8 ± 1.8 7.0 ± 2.5 -0.8 ± 1.7 -10 ± 23
Maxillary Premolar 99 9.4 ± 1.2 8.0 ± 1.3 -1.4 ± 1.1 -14 ± 11
Mandibular Premolar 24 7.8 ± 1.3 7.4 ± 1.3 -0.4 ± 1.0 -4 ± 13
*
RegenerOssTM, BioMet 3i, Palm Beach Gardens, FL 33410
†
Bio-Oss, Geistlich Pharma North America, Inc, Princeton, NJ 08540
‡
Guidor®, Sunstar Americas, Inc, Chicago, IL 60630
§
Cytoplast® PTFE Suture, Osteogenics Biomedical, Inc, Lubbock, TX 79424
║
H & H Company, Ontario, CA 91761

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Journal of Periodontology; Copyright 2013 DOI: 10.1902/jop.2013.120585

15
J Clin Periodontol 2013; doi: 10.1111/jcpe.12111

Dimensional alterations of Tobias Thalmair1, Stefan Fickl2,

David Schneider4, Marc Hinze1 and
Hannes Wachtel1,3

extraction sites after different 1

Private Institute for Periodontology and
Implantology, Munich, Germany; 2Department

alveolar ridge preservation

of Periodontology, Julius-Maximilians
University, Wurzburg, Germany; 3Department
of Prosthodontics, Dental School, Free
University of Berlin, Berlin, Germay; 4Clinic of

techniques – a volumetric study Fixed and Removable Prosthodontics and

Dental Material Science, University of Zurich,
Zurich, Switzerland

Thalmair T, Fickl S, Schneider D, Hinze M, Wachtel H. Dimensional alterations of

extraction sites after different alveolar ridge preservation techniques – a volumetric
study. J Clin Periodontol 2013; doi: 10.1111/jcpe.12111.

Abstract
Objectives: The aim of this randomized controlled clinical study was to assess
soft tissue contour changes after different alveolar ridge preservation procedures.
Material and Methods: Following tooth extraction, 30 patients were randomly
assigned to the following treatments (Tx) - Tx 1: xenogenic bone substitute (pre-
hydrated collagenated cortico-cancellous porcine bone) and free gingival graft; Tx
2: free gingival graft alone; Tx 3: xenogenic bone substitute; Tx 4: no further
treatment (control). Impressions were obtained before tooth extraction (baseline)
and 4 months after surgery. Cast models were optically scanned, digitally super-
imposed and horizontal measurements of the contour alterations between time
points were performed using digital imaging analysis.
Results: All groups displayed contour shrinkage at the buccal aspect ranging
from a mean horizontal reduction of !0.8 " 0.5 mm (Tx 1) to !2.3 " 1.1 mm
(control). Statistically significant differences were found between Tx 1 and Tx 4
as well as Tx 2 and Tx 4. A significant positive influence of the free gingival graft
on the maintenance of the ridge width was recorded (p < 0.001).
Conclusion: In this study, alveolar ridge preservation techniques were not able to
Key words: alveolar ridge preservation;
entirely compensate for alveolar ridge reduction. Covering the orifice of the dimensional alterations; extraction socket;
extraction socket with a free gingival tissue graft seems to have the potential to soft tissue punch
limit but not avoid the post-operative external contour shrinkage based on optical
scans. Accepted for publication 28 March 2013

Marked morphological and dimen- changes in dimensions are expected
sional alterations of the alveolar in hard tissue as well as soft tissue
ridge occur after tooth extraction (Van der Weijden et al. 2009). The
(Cardaropoli et al. 2003, Schropp resulting dimensional changes have
et al. 2003, Araujo and Lindhe, been evaluated by volumetric analy-
2005). Both horizontal and vertical sis in a clinical study (Schropp et al.
2003). The loss of volume in the hor-
Conflict of interest and source of izontal dimension amounts 5–7 mm
funding statement: within the first 12 months. This cor-
responds with approximately 50% of
The authors declare that they have no
the original width of the alveolar
conflicts of interest. This study was
bone (Schropp et al. 2003). The
supported in part by Tecnoss, Torino,
Italy.
resorption of the ridge is more
pronounced on the buccal than on
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
the lingual aspect of the extraction
socket (Araujo and Lindhe, 2005)
and limited to the marginal one-
third of the post-extraction site (Ara-
ujo et al. 2008). It was suggested
that the higher amount of resorption
at the buccal aspect is due to the
relatively greater proportion of bun-
dle or “tooth-derived” bone facially
that loses its function after tooth
extraction and undergoes atrophy
(Araujo and Lindhe, 2005). As the
buccal wall of the tooth socket is
frequently partially or completely
1
2 Thalmair et al.
resorbed (Araujo and Lindhe, 2005),
consequently a collapse of the
buccal soft tissue leads to marked
bucco-oral alterations (Schropp
et al. 2003). In particular, in the
anterior zone the mentioned altera-
tions of the extraction socket can
jeopardize the aesthetic outcome of
any dental treatment involving tooth
extraction.
To reduce volumetric changes
occurring after tooth extraction,
different treatment modalities have
been recommended. As implant
installation was not able to alter
biological procedures (Ara! ujo et al.
2005, Botticelli et al. 2004), it was
suggested that incorporation of
biomaterials into a fresh extraction
socket could be a suitable technique
for socket augmentation with the
ability to maintain the ridge dimen-
sion to a certain extent (Nevins et al.
2006, Cardaropoli et al. 2005). Sev-
eral studies have proposed various
ridge preservation techniques follow-
ing tooth extraction including the
placement of graft materials and/or
the use of occlusive membranes
(Camargnola et al. 2003, Lekovic
et al. 1998, Lekovic et al. 1997,
Cardaropoli et al. 2005) showing
that a significant reduction in alveo-
lar bone resorption could be
avoided. However, data obtained
from experimental studies showed
that incorporation of biomaterials
into the extraction socket is not able
to diminish the biological process of
the buccal bone plate (Fickl et al.
2008a, Fickl et al. 2008b).
Techniques to achieve soft tissue
closure of extraction sites have been
developed, mainly related to
immediate implant placement. Jung
et al. (2004) introduced the soft tissue
punch technique, the extraction
socket was filled with a bone substi-
tute and covered with an epithelial-
ized free connective tissue graft. It
was proposed that stabilizing the soft
tissue architecture with a free gingival
graft has beneficial effects on mini-
mizing the soft tissue shrinkage (Jung
et al. 2004). It was demonstrated that
placing a deproteinized bovine bone
material (DBBM) into the extraction
socket and closing the socket with a
free gingival graft was beneficial in
limiting the volumetric shrinkage
(Fickl et al. 2008b, Fickl et al. 2008a).
To date, it is still uncertain which
alveolar ridge preservation technique
is the most predictable. Therefore,
the aim of this clinical investigation
was to evaluate, to which extent a
filler or a soft tissue socket seal
contributes to ridge preservation.
Materials and Methods
The research protocol and the con-
sent form of this clinical investiga-
tion were approved by the ethical
committee of the Julius-Maximilians
University, Wuerzburg, Germany
(183/11).
Study population
Subjects selected for participating in
this prospective clinical study were
counselled and written informed
consent was obtained prior to the
surgical procedure (Helsinki Declara-
tion of 1975 as revised in 2000). The
patients were enrolled and treated in
a period of time between January
2011 and September 2011.
The study population consisted
of 30 adult patients (mean age 46.2,
range 24–72 years, 13 females)
requiring treatment of tooth extrac-
tion in the anterior zone ranging to
the second bicuspid. The reasons for
extraction included root fractures,
endodontic treatment failures and
advanced caries lesions.
The following exclusion criteria
were applied:
(1) Age <18 years.
(2) Smoking status of more than 10
cigarettes/day.
(3) Presence of relevant medical con-
ditions: Patients with diabetes mell-
itus, unstable or life-threatening
conditions, or requiring antibiotic
prophylaxis. Patients with medica-
tion of drugs influencing the bone
metabolism were also excluded.
(4) Pregnant or lactating women.
(5) History of malignancy, radiother-
apy, or chemotherapy for malignancy
in the past 5 years.
(6) History of autoimmune disease.
(7) Presence of acute periodontal or
periapical pathology.
Only teeth with an intact buccal
bone plate were included in the
study population. The condition of
the buccal bone plate was evaluated
intra-surgically after tooth extrac-
tion. All extraction sites presented a
minimum width of 2 mm of kerati-
nized gingival tissue.
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
All patients received instructions
in oral hygiene and underwent initial
periodontal evaluation including
professional tooth cleaning with scal-
ing and polishing until full-mouth
plaque score and full-mouth bleeding
score <20% were reached.
Inter-examiner accuracy control
All surgical procedures were per-
formed by four operators (H.W.,
T.T., S.F. and M.H.) in the same
clinic (Private Institute for Periodon-
tology and Implantology, Munich,
Germany).
To control the accuracy and
repeatability between surgeons, a cali-
bration meeting was held in Munich
(October 2010). Procedures were
explained using digital images and sur-
gical videos. Within the discussion at
the calibration meeting, it was decided
to make a variation to the original
approved protocol (two-arm study
with Tx 1 and Tx 3) and to add two
additional groups (Tx 2 and Tx 4).
Clinical procedure
Before surgery, impressions of the
jaws were obtained in a one-step/
two-viscosity technique with polye-
ther impression materials (Perma-
dyne Garant 2:1/Permadyne Penta
H; 3M Espe, St. Paul, MN, USA).
Following the administration of
local anaesthesia, an intra-sulcular
incision was performed and the teeth
were gently extracted without
elevation of a mucoperiosteal flap or
compromising the marginal gingiva.
Care was taken to produce as little
trauma as possible to the bone
around the alveolus. If necessary, the
teeth were sectioned to allow atrau-
matic extraction and, more impor-
tantly, preservation of all bone walls.
In case of deep fractured teeth, when
the remaining supragingival tooth
structure was insufficient for the use
of a forceps, a specific root extraction
device with intra-canalicular anchor-
age (Benex-Extractor, Zepf Medizin-
technik GmbH, Seitingen-Oberflacht,
Germany) was used to avoid trauma
to the surrounding tissues. The extr-
action sockets were carefully curetted
to remove granulation tissue.
Patients were enrolled sequen-
tially. A randomization list was
generated. Randomization envelopes
were supplied and numbered sequen-

tially containing the treatment
allocation according to the randomi-
zation list.
The extraction sites were ran-
domly assigned to one of the follow-
ing treatments:
Treatment 1 (Tx 1): The extrac-
tion socket was treated using the
socket seal technique (Jung et al.
2004). The internal marginal gingiva
of the extraction socket was deepi-
thelialized with a diamond bur until
bleeding was evident. The extraction
socket was filled with a xenogenic
bone substitute (pre-hydrated colla-
genated cortico-cancellous porcine
bone; mp3 OsteoBiol, Tecnoss, Tor-
ino, Italy) to the level of the bone
crest. A free gingival graft with a
thickness of 3 mm was harvested
from the palate/tuberosity and
sutured to the marginal gingiva of the
extraction socket with several inter-
rupted sutures (Seralene 7–0, Serag
Wiesner, Naila, Germany) (Fig. 1).
Treatment 2 (Tx 2): The internal
marginal gingiva of the extraction
socket was deepithelialized with a
diamond bur and a free gingival
graft was sutured into the orifice of
the extraction socket in the same
manner as in Tx 1, however, without
the use of a filler material.
Treatment 3 (Tx 3): The extrac-
tion socket was filled with mp3
(OsteoBiol, Tecnoss, Torino, Italy)
and secured with a non-resorbable
suture material (Gore-Tex CV5,
W.L. Gore & Associates, Putzbrunn,
Germany) without the use of a gingi-
val graft (Fig. 2).
Treatment 4 (Tx 4): The extrac-
tion socket remained with its blood
clot only (control).
Consecutively, a pre-fabricated
resin-bonded bridge was fixed to the
adjacent teeth without any contact
of the pontics to the extraction
socket with an auto-polymerizing
resin material (Clearfil Cores; Kura-
ray, Tokyo, Japan).
Post-surgical protocol
The patients were instructed to rinse
with 0.2% chlorhexidine digluconate
twice a day for at least 2 weeks
(Vaughan and Garnick, 1989). To
reduce swelling, Ibuprofen (600 mg)
was prescribed (Pearlman et al.
1997). Sutures were removed 7 days
after surgery. Polyether impressions
(Permadyne Garant 2:1/Permadyne
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Different alveolar ridge preservation techniques
(a)
(c)
Fig. 1. Treatment group 1. (a) after gentile extraction of tooth 21 the buccal wall is
intact, (b) a xenogenic bone substitute is applied into the extraction socket, (c) a gingi-
val autograft is sutured to the marginal soft tissue, (d) clinical situation 4 months
post-surgically.
Penta H; 3M Espe) were obtained
4 months after tooth extraction.
Evaluation of tissue contour changes
The analysis of the soft tissue contour
changes was performed at the Clinic
of Fixed and Removable Prosthodon-
tics and Dental Material Science,
University of Zurich, according to
previous studies (Fickl et al. 2009,
Thoma et al. 2010).
Master casts of each patient were
made with dental stone (CAM-Base,
Dentona AG, Dortmund, Germany)
utilizing the pre-extraction and fol-
low-up impressions after 4 months.
The cast models were optically
scanned and digitized (Iscan D101,
Imetric GmbH, Courgenay, Switzer-
land) creating STL files (Standard
Tessellation Language). The STL files
of these digital models representing
the two treatment time points were
imported into a specific software
(SMOP, Swissmeda, Zurich, Switzer-
land) and were superimposed accord-
ing to the buccal surface of the
adjacent teeth using the best-fit algo-
rithm. The same software was used to
measure the dimensional changes in
the relevant buccal alveolar ridge area
comparing the contour before tooth
extraction and 4 months after ther-
apy (Fig. 3). The area of measure-
ment was defined by a line parallel to
the tooth axis in the middle of the
3
(b)
(d)
mesial and distal papilla, by the
mucogingival line and the most coro-
nal contour line of the alveolar ridge.
As the size of this area differed from
site due to the difference in tooth/gap
size, the mean volume change per
area was calculated as a distance in
buccal direction (∆d [mm] = ∆vol
[mm3]/area [mm2]) to allow a direct
comparison of dimensional changes
between the sites.
Before the beginning of the evalua-
tion, a calibration exercise was per-
formed to obtain reproducibility for
the measurement of the relevant buccal
area. This analysis was conducted by
two examiners (D.S. and T.T.), one of
them was blinded (D.S.).
Statistical analysis
Sample size calculation was per-
formed on the results of previous
studies (Fickl et al. 2009, Fickl
et al. 2008b) and resulted in seven
subjects per group. For the primary
outcome variable (mean dimensional
change) it was assumed that the
true difference between groups
would amount to 0.75 mm with a
SD of 0.5. The Type I error proba-
bility was set at 0.05, the statistical
power at 80%.
Statistical analysis was performed
using a statistical software program
(SPSS 20, IBM Corporation, Arm-
onk, NY, USA) by a statistician (M.
4 Thalmair et al.

on the mean distance change. Spear-

man correlation was computed to
indicate associations between the
mean distance change and variables
(age, gender, jaw, jaw location and
method of extraction). Fisher’s exact
test was applied to find associations
between two binary variables. Krus-
kal–Wallis tested the influence of the
(a) (b) surgeons. The level of significance
was set at p < 0.05.

Results
All patients completed the study. Thirty
patients were included (13 females);
eight were smokers. The mean age was
46.2 years, ranging from 24 to 72 years
(Table 1 and Appendix S1).
(c) (d)
Qualitative assessment
Fig. 2. Treatment group 3. (a) tooth 14 needs to be extracted, (b) a xenogenic bone
substitute is applied into the extraction socket, (c) buccal view and (d) occlusal view at Healing of all treatment groups was
4 months post-surgically display the contour preservation. uneventful. No intra-operative or post-
operative complications occurred.
Clinically, 1 week after insertion of the
gingival graft, all areas were vascular-
ized, some parts were covered with
fibrin and responded by bleeding after
removal of the fibrinoid surface.
Necrotic parts or incomplete wound
closure were not observed.
After 4 months, all free gingival
grafts of group Tx 1 and Tx 2 were
(a) (b) fully integrated.

Quantitative assessment

The results of the dimensional evalua-

tion are displayed in Tables 2 and 3
and Appendix S1.
Horizontal contour shrinkage at the
buccal aspect during the 4 month heal-
ing period was observed in all groups
(c) (d) and ranged from !0.8 " 0.5 mm (Tx
1) to !2.3 " 1.1 mm (Tx 4/Control).
Fig. 3. Measured area of tissue volume changes. (a) and (b) superimposed images dem- The following dimensional changes
onstrating volumetric changes between baseline (yellow colour area) and 4 months occurred according to the treatment
(green colour area). (c) and (d) buccal and occlusal view of the measured area (region
of interest) in blue colour.
option (descriptive data between
stages):
Treatment 1 (Tx 1): Mean
Roos) at the Division of Biostatistics, rectness of the normality assumption. dimensional differences between
University of Zurich. Differences in mean distance change baseline and the 4 month scan were
The primary outcome variable was between groups were tested by apply- !0.79 " 0.5 mm (range: !0.13 to
horizontal soft tissue dimensional ing one-way analysis of variance !1.33 mm) buccally.
change at 4 months after tooth (ANOVA) and post hoc Scheffe test. Treatment 2 (Tx 2): Four
extraction. Influence of bone filler material months after tooth extraction, the
Descriptive statistics including box and soft tissue seal and other variables following dimensional changes were
plots were used to indicate the mean, like age, gender, jaw or tooth type recorded for the buccal aspect:
median, minimum, maximum values were the secondary outcome variables. !0.85 " 0.6 mm (range: !0.15 to
and the standard deviation in each Two-way ANOVA was used to iden- !1.60 mm).
treatment group. Kolmogorov–Smir- tify possible influence of the bone Treatment 3 (Tx 3): The mean
nov Test was used to check the cor- substitute filler and the soft tissue seal differences between baseline and the
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Different alveolar ridge preservation techniques 5

Table 1. Randomization of treatment options per extraction sites the application of a free gingival
Group Number Gender Smoker Maxilla Mandibula Reason for graft with or without a xenogenic
(M/F) (anter/ (premol) tooth bone substitute reduced post-opera-
premol) extraction tive tissue shrinkage to a certain
(endo/ extent. The outcome of this random-
fract/caries) ized controlled clinical investigation
demonstrated that the different alve-
Tx 1 8 3/5 2 7 (4/3) 1 5/3/–
olar ridge preservation techniques
Tx 2 8 7/1 1 7 (4/3) 1 4/2/2
Tx 3 7 5/2 2 5 (2/3) 2 3/2/2
resulted in less contour reduction
Tx 4 7 3/4 2 5 (2/3) 2 3/2/2 from the buccal aspect when com-
pared with unassisted socket healing.
endo, endodontic reason; fract, root fracture; caries, advanced caries lesion. The findings of this study can be
well compared to previous animal
Table 2. Descriptive statistics with measured area (mm2/mm3) and volume changes (mean, studies using a similar volumetric
minimum and maximum) data analysis. The horizontal contour
Group Area (mm2) ∆ Vol (mm3) Mean ∆ distance Min/max ∆ distance changes on the buccal aspect, after
(mm) (mm) extraction the socket was filled with
DBBM and covered with a free gin-
Tx 1 22.04 " 3.70 19.92 " 3.77 !0.79 " 0.5 !0.13 " 0.17/!1.33 " 0.21 gival graft, demonstrated !1.5 mm.
Tx 2 23.46 " 2.16 24.89 " 7.68 !0.85 " 0.6 !0.15 " 0.20/!1.60 " 0.19
Tx 3 19.63 " 1.29 32.89 " 6.96 !1.45 " 0.7 !0.73 " 0.15/!2.14 " 0.35
It was concluded that the application
Tx 4 19.72 " 3.35 41.41 " 15.96 !2.29 " 1.1 !1.23 " 0.26/!3.34 " 0.54 of DBBM seemed to limit the tissue
shrinkage (Fickl et al. 2008b).
A xenogenic porcine bone substi-
Table 3. Volumetric data describing the distribution according to mean dimensional change tute was used in this clinical trial, it
Group <0.5 mm 0.5–1.0 mm 1.0–1.5 mm 1.5–2.0 mm >2.0 mm was investigated as natural scaffold for
new bone formation. An almost com-
Tx 1 3 2 3 – – plete incorporation of the cortico-can-
Tx 2 2 3 2 1 – cellous particles surrounded by vital
Tx 3 – 2 2 2 1 bone was observed (Barone et al.
Tx 4 – – 2 1 3
2008). Compared to ridge preservation
with a bovine bone substitute, the
grafted sites comprised connective tis-
4 month scans were !1.45 " 0.7 mm Spearman correlation did not sue including the graft particles and
(range: !0.73 to !2.14 mm). show any significant association small amounts of newly formed bone
Treatment 4 (Tx 4): The mean between predictors (age, gender, (Carmagnola et al. 2003).
difference of the dimensional con- smoking, jaw, jaw location and The results of this study indicate
tour changes was !2.29 " 1.1 mm method of extraction) and the mean that the free gingival graft for cover-
(range: !1.23 to !3.34 mm). distance difference. ing the extraction socket revealed
The comparison of the groups by Kruskal–Wallis test revealed no statistically significant superior
unpaired t-tests (one-way ANOVA) statistically significant difference results in minimizing the buccal con-
resulted in significant differences in among the different surgeons tour shrinkage, irrespective of addi-
dimensional change between the test (p = 0.964). tionally a xenogenic bone substitute
groups Tx 1 and Tx 2 compared was applicated or not. The biological
with control group Tx 4. No other integration of the free gingival graft
Discussion
significant differences were observed was successful as no complication
between groups (Fig. 4). Indications for ridge preservation regarding graft necrosis could be
Two-way ANOVA showed a signifi- are maintaining a stable ridge vol- observed. It can be assumed that the
cant influence of the soft tissue ume for optimizing functional and soft tissue cover at the extraction site
socket seal leading to a lower degree aesthetic outcome and simplifying has the potential to limit the post-
in shrinkage (B = 1.05; p < 0.001). the treatment procedures subsequent operative contour alterations to a
The influence of the filler was esti- to ridge preservation. certain extent.
mated to be not significant This study evaluated different This is in accordance with the
(B = 0.42; p = 0.125). techniques for alveolar ridge preser- clinical study of Jung et al. (2004),
The extraction procedure – sepa- vation following tooth extraction, who reported that 3 weeks after sur-
ration of the root, extraction with generating sufficient soft tissue vol- gery, 99.7% of the soft tissue grafts
forceps or with a mechanical device ume for the time of implant place- were fully integrated (Jung et al.
– had no influence on the buccal ment thus simplifying implantation 2004). Landsberg and Bichacho
contour changes. procedures at earlier time points. (1994) stated that due to primary
There was no difference in the The use of xenogenic bone substi- wound closure and the additional
volume alterations regarding the tute, a free gingival graft and the mechanical stability of the free auto-
location of the tooth. No difference combination of both for alveolar graft, the soft tissue collapse might
was found between teeth located in ridge preservation were assessed. be avoided to a certain extent. A sta-
maxilla or mandibula. Preserving the extraction socket by tistically significant effect of the
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
6 Thalmair et al.
Fig. 4. Volumetric changes indicated as mean change distance in millimetres.
gingival autograft with respect to the
maintenance of the tissue contours
at the buccal aspect was found
(Landsberg and Bichacho, 1994).
Within the limits of this study
evaluating the soft tissue contour vol-
ume, primary wound closure by
means of a free gingival graft to seal
the orifice of the extraction socket
might be more beneficial compared to
healing by secondary intention. This
is contrary to several clinical trials
reporting successful treatment out-
comes with secondary wound healing
(Camargnola et al. 2003, Serino et al.
2003, Serino et al. 2008).
Ridge preservation by simply
using a xenogenic bone substitute
seemed to be more effective than
healing by clot alone, but this differ-
ence was statistically not significant
in the present investigation. This
lack of evidence may be due to the
small number of subjects. This find-
ing would be in accordance with sev-
eral clinical trials indicating a strong
evidence that ridge preservation with
grafting materials is more effective
(Barone et al. 2008, Cardaropoli and
Cardaropoli, 2008). However, it was
demonstrated that in marginal por-
tions of some sockets bone substitute
particles surrounded by granulation
tissue occurred (Araujo et al. 2010,
Araujo and Lindhe, 2009).
According to previous studies
showing that the resorption of the
alveolar ridge is more pronounced
on the buccal than on the lingual
aspect of the extraction socket (Ara-
ujo and Lindhe, 2005, Schropp et al.
2003), only the buccal soft tissue
compartment of the experimental
sites was analysed. This is a limita-
tion of the study. Because measure-
ments were based on master models,
no statements can be made as to
whether the documented horizontal
volume resorption was caused by
loss of soft tissue or underlying
bone. However, no complete preser-
vation of the outline of the alveolar
crest could be assessed in particular
at the buccal aspect.
The applied technique showed a
high reproducibility and an excellent
accuracy for measuring volume
changes with a measurement error
below 10 mm (Mehl et al. 1997,
Windisch et al. 2007). This method
offers advantages including its non-
invasive character, absence of radia-
tion and the fact that it can easily be
applied. Currently, there is one
shortcoming of the technique
because optical scans were per-
formed on study casts in this study.
The accuracy of the method is highly
influenced by the accuracy of the
impressions and the casts.
Another limitation of the study is
the small number of patients in each
group. Further clinical investigation
should be conducted to recruit a
larger patient collective to increase
the statistical power of clinical inves-
tigations.
It is generally assumed that the
anterior segment of the dentition
responded differently than premolar
sites to horizontal ridge reduction.
This may indicate that anterior sites
are more susceptible to ridge altera-
tions than premolar sites. The results
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
of this clinical trial did not show a
difference in location and type of
tooth.
The most important clinical
impact of alveolar ridge preservation
techniques on patient-related out-
come should be to optimize implant
placement in the correct position and
to avoid additional augmentation
procedure. However, a statistical sig-
nificance favouring one alveolar ridge
preservation technique does not nec-
essarily lead to a clinical benefit for
the patient, unless the whole treat-
ment is simplified or made more suc-
cessful. There is still a lack of
sufficient evidence on implant-related
outcome. Only few studies reported
on a possible influence of alveolar
ridge preservation on placing
implants and need of further augmen-
tation therapies (Serino et al. 2008,
Fiorellini et al. 2005). Therefore, the
positive influence of alveolar ridge
preservation techniques on patient-
related outcome may be attributed
more to achieving enhanced restor-
ative and aesthetic outcomes, as well
as better maintenance of healthy peri-
implant soft tissues (Vignoletti et al.
2012).
In conclusion, the present clinical
study demonstrates that the investi-
gated alveolar ridge preservation
techniques were not able to prevent
soft tissue contour alterations entirely
after tooth extraction. It appears that
complete ridge preservation is not
possible with the alveolar ridge pres-
ervation techniques evaluated. The
use of a free gingival graft covering
the extraction socket was beneficial
for maintaining soft tissue volume.
More studies including a higher num-
ber of patients or sites are needed to
further investigate these findings.
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autogenous free connective tissue
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post-extraction sites.
Practical implications: In clinical
cases where significant ridge resorp-
tion is expected after tooth extrac-
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– with or without the application of
7
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Vignoletti, F., Matesanz, P., Rodrigo, D., Figu-
ero, E., Martin, C. & Sanz, M. (2012) Surgical
protocols for ridge preservation after tooth
extraction. A systematic review. Clinical Oral
Implants Research 23(Suppl 5), 22–38.
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P., Ender, A. & Hammerle, C. H. (2007) A
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Supporting Information
Additional Supporting Information
may be found in the online version
of this article:
Appendix S1. Individual data of the
30 patients. The table reports base-
line patient characteristics, treatment
assignement, surgeon and outcome
variables for each patient. The volu-
metric changes from baseline to 4
months postoperative are expressed
in mean, minimum and maximum
change distance.
Address:
Tobias Thalmair
Praxis Dr. Thalmair
Kammergasse 10
85354 Freising
Germany
E-mail: t.thalmair@praxis-thalmair.de
a bone substitute – could provide a
relatively simple and inexpensive
treatment to limit the contour
shrinkage, eventually eliminating
later augmentation procedures.
Fabio Vignoletti Surgical protocols for ridge
Paula Matesanz
Daniel Rodrigo
preservation after tooth extraction.
Elena Figuero A systematic review
Conchita Martin
Mariano Sanz

Authors’ affiliations:
Fabio Vignoletti, Paula Matesanz, Daniel Rodrigo,
Elena Figuero, Conchita Martin, Mariano Sanz,
ETEP Research Group, University Complutense,
Madrid, Spain
Key words: bone grafts, bone regeneration, bone substitutes, dental implants, ridge preserva-
tion, systematic review, tooth extraction
Abstract

Corresponding author:
Objective: This systematic review aims to evaluate the scientific evidence on the efficacy in the
Prof. Mariano Sanz surgical protocols designed for preserving the alveolar ridge after tooth extraction and to evaluate
Facultad de Odontologı́a how these techniques affect the placement of dental implants and the final implant supported
Universidad Complutense de Madrid
Plaza Ramón y Cajal, 28040 Madrid, Spain restoration.
Tel.: +34 913 941 901 Material and methods: A thorough search in MEDLINE-PubMed, Embase and the Cochrane Central
Fax: +34 913 941 910 Register of controlled trials (CENTRAL) was conducted up to February 2011. Randomized clinical
e-mail: marianosanz@odon.ucm.es
trials and prospective cohort studies with a follow-up of at least 3 months reporting changes on
both the hard and soft tissues (height and/or width) of the alveolar process (mm or %) after tooth
extraction were considered for inclusion.
Results: The screening of titles and abstracts resulted in 14 publications meeting the eligibility
criteria. Data from nine of these 14 studies could be grouped in the meta-analyses. Results from
the meta-analyses showed a statistically significant greater ridge reduction in bone height for
control groups as compared to test groups (weighted mean differences, WMD = !1.47 mm; 95% CI
[!1.982, !0.953]; P < 0.001; heterogeneity: I2 = 13.1%; v2 P-value = 0.314) and a significant greater
reduction in bone width for control groups compared to the test groups (WMD = !1.830 mm; 95%
CI [!2.947, !0.732]; P = 0.001; heterogeneity: I2 = 0%; v2 P-value = 0.837). Subgroup analysis was
based on the surgical protocol used for the socket preservation (flapless/flapped, barrier
membrane/no membrane, primary intention healing/no primary healing) and on the measurement
method utilized to evaluate morphological changes. Meta-regression analyses demonstrated a
statistically significant difference favoring the flapped subgroup in terms of bone width (meta-
regression; slope = 2.26; 95% IC [1.01; 3.51]; P = 0.003).
Conclusions: The potential benefit of socket preservation therapies was demonstrated resulting in
significantly less vertical and horizontal contraction of the alveolar bone crest. The scientific
evidence does not provide clear guidelines in regards to the type of biomaterial, or surgical
procedure, although a significant positive effect of the flapped surgery was observed. There are no
data available to draw conclusions on the consequences of such benefits on the long-term
outcomes of implant therapy.

Date:
Accepted 26 August 2011
To cite this article:
Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C,
Sanz M. Surgical protocols for ridge preservation after tooth
extraction. A systematic review.
Clin. Oral Impl. Res. 23(Suppl. 5), 2012, 22–38
doi: 10.1111/j.1600-0501.2011.02331.x
The alveolar processes in the jaws are tooth-
dependent structures that will undergo signif-
icant structural changes whenever the teeth
are lost. The dynamics and magnitude of
these changes have been investigated in the
dog model (Kuboki et al. 1988; Devlin et al.
1997; Cardaropoli et al. 2003; Araujo & Lind-
he 2005; van Kesteren et al. 2010) as well as
in humans (Amler et al. 1960; Evian et al.
1982; Devlin & Sloan 2002; Trombelli et al.
2008). These investigations have identified
the key processes of tissue modelling and
remodelling after tooth extraction that even-
tually lead to a reduction on the overall ridge
dimensions with significant changes in both
the buccal and lingual bone crests.
The amount of vertical and horizontal
resorption of the socket walls has been inves-
tigated with different methods, ranging from
studying and measuring cast models (Pietro-
kovski & Massler 1967; Johnson 1969;
Schropp et al. 2003), to radiographic analysis

© 2011 John Wiley & Sons A/S 22


(Schropp et al. 2003), clinical assessment
with individually pre-fabricated acrylic stents
during re-entry surgeries (Lekovic et al. 1998;
Camargo et al. 2000) and histological studies
in experimental animal models (Cardaropoli
et al. 2003; Araujo & Lindhe 2005). These
studies have evidenced that most of the
resorption occurs during the first 3 months
of healing, although dimensional changes can
be observed up to 1 year after tooth extrac-
tion, resulting in approximately 50% reduc-
tion of the bucco-lingual dimension of the
alveolar ridge (Schropp et al. 2003), mainly
due to the resorption of the buccal bone plate
(Araujo & Lindhe 2005).
The clinical consequences of these physio-
logical hard and soft tissue changes may
affect the outcome of the ensuing therapies
aimed to restore the lost dentition, either by
limiting the bone availability for ideal
implant placement or by compromising the
aesthetic result of the prosthetic restorations.
To counteract these early tissue changes after
tooth extraction, different socket preservation
therapies have been proposed, ranging from a
careful flapless tooth extraction aiming for an
undisturbed socket healing (Fickl et al.
2008a, 2008b), to the immediate placement
of dental implants (Paolantonio et al. 2001),
to filling the resulting alveolar socket with
different grafting materials, with and without
barrier membranes (Fickl et al. 2008a, 2008b).
The possible beneficial effect of a flapless
surgery during tooth extraction for limiting
the resorptive process of the alveolar crest
has been investigated in pre-clinical models
by comparing the outcomes with a flapped
conventional surgery. Although some studies
have shown slightly less pronounced bone
remodelling of the alveolar ridge after flapless
tooth extraction (Fickl et al. 2008a, 2008b),
other studies have failed to encounter signifi-
cant differences between flapped and flapless
tooth extractions (Araujo & Lindhe 2009).
Similarly, the possible beneficial effect of
using grafting procedures or guided bone
regeneration (GBR) to preserve the ridge after
tooth extraction has been tested in both ani-
mal and human studies. Using the dog experi-
mental model (Araujo & Lindhe 2009; Araujo
et al. 2008) filled the socket immediately after
tooth extraction with bovine-derived hydroxy-
apatite or with an autogenous bone graft (Ara-
ujo & Lindhe 2011). While the placement of
the xenograft counteracted the ridge contrac-
tion in the buco-lingual dimension, grafting
with autogenous bone did not significantly
alter the ridge resorptive process. In humans,
the application of regenerative bio-materials,
such as bone autografts, allografts, guided tis-
© 2011 John Wiley & Sons A/S
Vignoletti et al " Ridge preservation after tooth extraction
sue regeneration procedures, xenografts and
most recently, growth factors, has also been
evaluated with varying degrees of success to
maintain the anatomical dimensions of the
alveolar ridge after tooth extraction. A recent
systematic review (Ten Heggeler et al. 2010)
evaluated the efficacy of these therapies in
non-molar alveolar regions suggesting that
these techniques may not prevent the physio-
logical resorptive bone processes after tooth
extraction, although they may aid in reducing
the resulting bone dimensional changes. This
investigation, however, could not draw firm
conclusions due to the limitations in the
existing clinical research.
In terms of histological outcomes in
humans (Becker et al. 1999), used different
biomaterials, such as demineralized freeze-
dried bone, autologous bone, human morpho-
genetic proteins in a carrier to graft human
extraction sockets, reporting that the graft
materials were, 3–7 months later, mainly
surrounded by connective tissue. In contrast
(Artzi et al. 2000), using the same xenogeneic
graft material found the graft particles in
direct contact with bone, although in a simi-
lar study, using the same grafting material
(Carmagnola et al. 2003) found the graft par-
ticles remained within the socket more than
6 months after the extraction and only 40%
of the particles were in direct contact with
bone. It is, therefore, uncertain whether these
socket preservation therapies improve the
outcomes of the different rehabilitation
approaches after tooth loss.
The objective of the present study was to
systematically review all the scientific evi-
dence regarding these therapeutic interven-
tions for socket preservation after tooth
extraction and to assess systematically
the potential benefit of such techniques/
materials when compared with what occurs
when the socket is left to heal spontane-
ously.
The specific objectives were: (1) to describe
the surgical techniques and biomaterials
most commonly used to preserve the socket
architecture after tooth extraction; (2) to eval-
uate their expected outcome on the alveolar
ridge dimension and (3) to assess their impact
on the bone availability for ideal implant
placement or on the resulting prosthetic res-
toration.
Material and methods
Development of a protocol
A protocol covering all aspects of the system-
atic review methodology was developed
before the start of the review, including the
following definitions (Needleman 2002):
• Focused question.
• Study population.
• Types of intervention.
• Types of comparisons.
• Search strategy.
• Eligibility criteria for study inclusion.
• Outcome measures.
• Screening methods and data extraction.
• Quality assessment and data synthesis.
• Assessment of heterogeneity and drawing
of conclusions.
Focused question
“Which are the effects of the different socket
preservation approaches used immediately
after tooth extraction, compared to the spon-
taneous healing of the socket, in terms of the
alveolar ridge hard and soft tissue dimen-
sional changes and in terms of providing suf-
ficient bone availability for implant
placement and/or a restorative final success-
ful outcome?”
Population of study, type of intervention and type of
comparison
The population of interest for this review
was represented by humans with at least one
tooth to be extracted, older than 18 years and
in good general health. A minimum sample
size (10 subjects per group) was established
in an attempt to minimize the publication
bias. The definition used for extraction
socket preservation therapy was: “Any thera-
peutic approach carried out immediately after
tooth extraction aimed to preserve the alveo-
lar socket architecture and to provide the
maximum bone availability for implant
placement.”
The specific therapeutic interventions eval-
uated in this study were:
• filling the socket with autologous bone
grafts or bone substitutes (allogenic, xeno-
genic and synthetic grafts);
• isolating the socket with the use of bar-
rier membranes, soft tissue autografts or
soft tissue substitutes (allogenic and oth-
ers) and,
• promoting the healing process of the
socket by the addition of growth factors
or bone morphogenetic proteins.
These interventions were compared to the
spontaneous healing of the socket.
Search strategy
Three electronic databases were used as
sources in the search for studies satisfying the
23 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38
Vignoletti et al " Ridge preservation after tooth extraction
inclusion criteria: (1) The National Library of
Medicine (MEDLINE via Pubmed); (2) Embase
and (3) Cochrane Central Register of Con-
trolled Trials. These databases were searched
for studies published until February 2011.
The search was limited to human subjects.
The following search terms were used:
Population
(<[text words] Tooth> OR <[MeSH terms/
all subheadings] “Tooth”>) AND
([text words] Extraction)
OR
(<[Text words] Tooth extraction OR Extrac-
tion socket* OR Alveolar socket* OR dental
extraction* OR tooth removal OR socket*
OR ridge-socket* OR post-extraction socket*
OR fresh extraction socket* OR alveolar
crest> OR <[MeSH terms/all subheadings]
“Tooth Extraction*” OR “Tooth socket*”>)
Intervention
[text words] Socket*preservation OR Ridge
preservation OR bone preservation OR socket*
seal OR Site* preservation OR Bone filler* OR
Autologous bone graft* OR autologous bone
OR autogenous bone graft* OR Autogenous
bone OR bone substitute* OR growth factor*
OR rhBMP OR bone morphogenetic protein*
OR allogenic graft* or Allograft* OR xenogen-
ic graft* OR OR xenogeneic graft* OR xeno-
graft* OR synthetic graft* OR Barrier
membrane* OR membrane* OR resorbable
membrane* or non-resorbable membrane OR
guided bone regeneration OR GBR OR freeze
dried bone allograft* OR demineralized freeze
dried bone allograft* OR DFDBA OR FDBA
OR Bio-Oss OR Bio-Oss Collagen OR Allo-
plast* OR tricalciumphosphate OR cerasorb
OR Bioglass OR polymeric OR collagen sponge
OR Collagen OR collagen fleece OR collagen
plug* OR Bioguide OR Ossix OR Gore tex OR
ePTFE OR soft tissue* autograft* OR connec-
tive tissue graft* OR punch OR free gingival
graft* OR soft tissue* substitute* OR allogenic
soft tissue* OR alloderm OR acellular dermal
matrix OR collagen matrix.
There were no language restrictions. All
reference lists of the selected studies were
checked for cross-references. The following
journals were hand-searched: Journal of Clin-
ical Periodontology, Journal of Periodontol-
ogy, Journal of Periodontal Research;
Clinical Oral Implants Research, Interna-
tional Journal of Oral & Maxillofacial
Implants and Clinical Implant Dentistry and
Related Research.
Eligibility criteria for study inclusion
Randomized clinical trials (RCT) or prospec-
tive cohort studies with a follow-up of at
24 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38
least 3 months after tooth extraction were
considered for inclusion in this review.
Outcome measures
The primary outcome variable chosen was the
bone dimensional changes occurring in the
socket wall after the tooth extraction and
the socket preservation therapy, measured as
the changes in the height and width of the
alveolar process (mm or %).
As secondary outcome variables, we con-
sidered the soft tissue dimensional changes
(in mm or %), the presence and amount of
keratinized tissue at time of implant place-
ment (yes/no or mm), the changes in clinical
attachment levels (CAL) evaluated at the
mesial and distal adjacent teeth, the avail-
ability of bone for implant placement (yes or
no), the need for soft and/or hard tissue aug-
mentation techniques at the time of implant
placement (number and type), the outcome of
the final implant supported restoration evalu-
ated in terms of the prosthetic and/or aes-
thetic result and assessed by the dentist or
the patient using different parameters or
indexes (Jemt index, VAS scale, etc.), and the
peri-implant health status evaluated radio-
graphically or clinically by means of probing
pocket depths, CAL, bleeding on probing and
the plaque index.
Screening methods and data extraction
First, two reviewers (PM and DR) screened
independently the titles and abstracts and did
the primary search. Subsequently, the studies
appearing to meet the inclusion criteria, or
those with insufficient data in the title and
abstract to make a clear decision, were
selected for evaluation of the full manuscript,
which was carried out independently by the
same two reviewers who determined their
eligibility. Any disagreement was resolved by
discussion with a third reviewer (FV). To pre-
vent selection bias, the reviewers were blind
to the name of the authors, institutions and
journal titles. All studies that met the inclu-
sion criteria underwent a validity assess-
ment. The reasons for rejecting studies at
this or at subsequent stages were recorded.
Special attention was paid to duplicate publi-
cations to avoid a likely bigger impact of the
same data on the overall result.
Data extraction
Two reviewers (PM and DR) independently
extracted the data using specially designed
data extraction forms. Any disagreement was
discussed and a third reviewer (EF or FV) was
consulted when necessary. The inter-
reviewer reliability of the data extraction was
calculated by determining the percentage of
agreement and the correlation coefficients
with Kappa analysis. Authors of studies were
contacted for clarification when data were
incomplete or missing. Data were excluded
until further clarification could be available
if agreement could not be reached. When the
results of a study were published more than
once or if the results were presented in a
number of publications, the most complete
dataset was included only once.
Quality assessment
The quality assessment of the included stud-
ies was undertaken independently and in
duplicate by one reviewer (PM) who was blind
to the name of the authors, institutions and
journal titles. This assessment was based on
the study design utilized according to the fol-
lowing criteria for Randomized controlled tri-
als: Quality assessment was carried out
following the recommendations by Cochrane
for assessing risk of bias (Higgins et al. 2009)
and also based on criteria proposed by Ten
Heggeler et al. (2010), which are based on the
RCT-checklist of the Dutch Cochrane Center
(2009), the CONSORT-statements (Schulz
et al. 2010), MOOSE-statement (Stroup et al.
2000), STROBE statements (von Elm et al.
2007) and the recommendations by Needle-
man (2002) and Esposito et al. (2001). Studies
were defined as low risk of bias if these six
criteria were clearly met in the study: random
allocation, definition of inclusion/exclusion
criteria for selecting the population, measures
to blind the patient and examiner, selection
of a representative population group, use of
identical treatment between groups except for
the intervention and detailed reporting of the
follow-up. When missing one of these criteria,
the study was classified as moderate potential
risk of bias. Missing two or more of these cri-
teria resulted in a high potential risk of bias
(Ten Heggeler et al. 2010).
The statistical heterogeneity among studies
was assessed using the Q test according to
Dersimonian and Laird, as well as the I2
index (Higgins et al. 2003) to know the per-
centage of variation in the global estimate
that was attributable to heterogeneity (I2 =
25%: low; I2 = 50%: moderate; I2 = 75%:
high heterogeneity). When the heterogeneity
values were high, a subgroup analysis was
carried out using the following explanatory
variables: (1) use of membrane (Yes/No); (2)
surgical technique (flap Yes/No); (3) primary
wound closure and (4) measurement tool
used to assess the morphological changes.
This subgroup analysis was performed using
meta-regression.
© 2011 John Wiley & Sons A/S
 Vignoletti et al " Ridge preservation after tooth extraction

Data analysis
To summarize and to compare the selected
studies, the data on the primary outcome
(mean bone dimensional changes) were pooled
and analysed using means and 95% confi-
dence intervals. The data on secondary out-
comes were analysed depending on the type of
variable. For dichotomous variables (e.g. suc-
cessful implant placement), the estimates of
the effect were expressed as risk ratio and
95% confidence intervals. For continuous
variables (bone level changes, soft tissue
changes), weighted mean differences (WMD)
and 95% confidence intervals were used.
The study-specific estimates were pooled
using both the fixed effect model (Mantel-
Haenzel-Peto test) and the random effect
model (Dersimonian-Laird test). If a signifi-
cant heterogeneity was found, the random
effect model results were presented.
A Forest Plot was created to illustrate the
effects on the meta-analysis of the different
studies and the global estimation. The publi-
cation bias was evaluated using a Funnel
plot and the Egger’s linear regression
method. A sensitivity analysis of the meta-
analysis results was also performed (Tobias
1999). STATA® (StataCorp LP, Lakeway
Drive, College Station, TX, USA) inter-
cooled software was used to perform all
analyses. Statistical significance was defined
as a P-value <0.05.
veling 2010) (Table 1). Two studies were con-
trolled clinical studies, one with two study
groups and a 6-month follow-up period (Seri-
no et al. 2003) and the other with three study
groups and a 3-month follow-up (Serino et al.
2008). Six studies presented a split-mouth
design, whereas eight studies presented a par-
allel design.
The study population ranged from 10 indi-
viduals to 125. Smoking habit was reported
in four studies (Hoad-Reddick et al. 1994; Le-
kovic et al. 1997; Lekovic et al. 1998; Bolouri
et al. 2001; Froum et al. 2002; Iasella et al.
2003; Fiorellini et al. 2005; Barone et al.
2008; Aimetti et al. 2009; Crespi et al. 2009;
Casado et al. 2010; Oghli & Steveling 2010)
ranging from 0% to 12%. The periodontal
status of the extracted teeth was defined in
three studies (Serino et al. 2003; Serino et al.
2008). The localization of extracted teeth in
the mouth was reported in nine studies
(Hoad-Reddick et al. 1994; Lekovic et al.
Identification
Records identified through
database searching
(n = 296)
1997; Lekovic et al. 1998; Bolouri et al. 2001;
Froum et al. 2002; Iasella et al. 2003; Fiorel-
lini et al. 2005; Barone et al. 2008; Aimetti
et al. 2009; Crespi et al. 2009; Casado et al.
2010; Oghli & Steveling 2010) in which
most, studied non-molar sites (Hoad-Reddick
et al. 1994; Lekovic et al. 1997; Lekovic et al.
1998; Bolouri et al. 2001; Froum et al. 2002;
Iasella et al. 2003; Fiorellini et al. 2005; Ba-
rone et al. 2008; Aimetti et al. 2009; Crespi
et al. 2009; Casado et al. 2010; Oghli & Ste-
veling 2010), although some were very spe-
cific to mandibular (Hoad-Reddick et al.
1994) or maxillary anterior teeth (Aimetti
et al. 2009), whereas others included any
teeth (Bolouri et al. 2001; Crespi et al. 2009).
Type of intervention and type of biomaterials
Most of the studies (Hoad-Reddick et al.
1994; Lekovic et al. 1997; Lekovic et al.
1998; Bolouri et al. 2001; Froum et al. 2002;
Iasella et al. 2003; Fiorellini et al. 2005; Ba-
Additional records identified
through other sources
(n = 0)

Results Records after duplicates removed

Screening (n = 296)
Screening
The search strategy resulted in 296 articles.
After an initial phase of screening (agreement
between reviewers of 89.53%; kappa = 0.46), Records screened Records excluded
17 potentially relevant articles were identi-
(n = 296) (n = 279)
fied. After reading the complete manuscripts,
three studies were excluded due to inade-
Eligibility
quate study design (Block & Jackson 2006); Full-text articles Full-text articles
inadequate control group (Yilmaz et al. 1998) assessed for eligibility excluded, with reasons
and due to only reporting secondary out-
(n = 17) (n = 3)
comes (Norton et al. 2003). Hand-search or
cross-reference did not result in any addi- Did not fulfill the
tional article. Therefore, 14 studies were Studies included in inclusion criteria
finally included (Fig. 1).
Inclusion qualitative synthesis

(n = 14)
Study design and study population
Twelve studies were RCTs with two to five
study groups and with a follow-up period Studies included in
between 3 and 7 months (Hoad-Reddick et al. quantitative synthesis
1994; Lekovic et al. 1997; Lekovic et al. (meta-analysis)
1998; Bolouri et al. 2001; Froum et al. 2002;
(n = 9)
Iasella et al. 2003; Fiorellini et al. 2005; Ba-
rone et al. 2008; Aimetti et al. 2009; Crespi
et al. 2009; Casado et al. 2010; Oghli & Ste-
Fig. 1. Flow diagram (PRISMA format) of the screening and selection process.

© 2011 John Wiley & Sons A/S 25 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38
 Table 1. Methods, participants, interventions, outcomes, site and funding of the selected studies

26 |
Study (#) Method Participants Surgical considerations Intervention Measurement method Outcome Site and funding
Hoad-Reddick RCT Two 18 individuals Flapless Primary Test: Hydroxyapatite granules Lateral Hard tissue Not
et al. study (-na) Aged closure: na Control: No socket filling cephalographs dimensions: defect explained Not
(1994) groups Parallel 54.4 years Type of socket: and dental height (mm) available
(1) groups 6 months Smoking habit: na pantomograms
follow-up na Periodontal

F
status: na
Lekovic RCT Two 10 individuals Flap Primary Test: ePTFE® membrane Reentry surgery Hard tissue Yugoslavia Not
et al. study (-3) Aged closure: YES Control: dimensions: defect available
(1997) groups Split 49.8 years Type of socket: No socket filling height (mm), defect

O
(2) mouth 6 months Smoking habit: na width (mm)
follow-up na Periodontal
status: na
Lekovic RCT Two 16 individuals Flap Primary Test: membrane of glycolide Reentry surgery Hard tissue Yugoslavia Not
et al. study (-0) Aged closure: YES and lactide polimers Control: dimensions: defect available

O
(1998) groups Split 52.6 years Type of socket: No socket filling height (mm), defect
(3) mouth 6 months Smoking habit: na width (mm)

Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38

follow-up na Periodontal

R
status: na
Vignoletti et al " Ridge preservation after tooth extraction

Bolouri RCT Two 18 individuals Flap Primary Test: Bioplant HTR® Control: Hard tissue USA Bioplant Inc.
et al. study (-14) Aged closure: YES No socket filling dimensions: optical South Norwalk,
(2001) groups Split 54.4 years Type of socket: density CT

P
(4) mouth 24 months Smoking habit: na
follow-up na Periodontal
status: na
Froum RCT Three 19 individuals Flap Primary Test 1: Bioactive glass Test 2: Histological Histological analysis USA Orthovita
et al. study (-na) Aged closure: YES DFDBA Control: No socket analysis
(2002) groups Split na Smoking Type of socket: filling

D
(5) mouth 6–8 months habit: 0% 4-wall
follow-up Periodontal
status: na

E
Serino CT Two 45 individuals Flap Primary Test: Sponge of polylactide- Reentry Hard tissue Italy Not
et al. study (-na) Aged closure: YES polyglycolide acid Control: No surgery + stent dimensions: defect available
(2003) groups Parallel na Smoking Type of socket: socket filling height (mm)
(6) groups 6 month habit: na na Histological analysis

T
follow-up Periodontal
status:
periodontitis

C
Iasella RCT Two 24 individuals Flap Primary Test: FDBA + tetracycline + Clinical + stent Hard tissue USA Not
et al. study (-na) Aged closure: NO collagen dimensions: defect available
(2003) groups Parallel 51.5 Smoking Type of socket: \ mombrane Control: height (mm), defect
(7) groups 4–6 months habit: na na No socket filling width (mm) Soft

E
follow-up Periodontal tissue dimensions
status: Histological analysis
periodontitis
Fiorellini RCT Five 80 individuals Flap Primary Test 1: 0.75 mg/ml rhBMP/ACS CT scan Defect height and USA Wyeth/Genetics

R
et al. study (-0) Aged closure: YES Test 2: 1.50 mg/ml rhBMP/ACS width (mm CTscan) Institute,
(2005) groups Parallel 47.4 Smoking Type of socket: Control 1: No socket filling Need for Cambridge, MA
(8) groups 6 months habit: na 3-wall(no buccal Control 2: placebo augmentation
follow-up Periodontal wall) technique

R
status: na Histological analysis
Barone RCT Two 40 individuals Flap Primary Test: Corticocancellous porcine Reentry + stent Hard tissue Italy Not
et al. study (-0) Aged: na closure: YES bone + collagen membrane dimensions: defect available
(2008) groups Parallel Smoking habit: Type of socket: Control: No socket filling height (mm), defect

O
(9) groups 7 months 12.5% 4-wall width (mm)
follow-up Periodontal Histological analysis
status: na

© 2011 John Wiley & Sons A/S

C
 Table 1. (continued)
Study (#) Method Participants Surgical considerations Intervention Measurement method Outcome Site and funding
Serino CT Two 20 individuals Flap Primary Test: Sponge of Histological Histological Italy Not
et al. study (-0) Aged: closure: NO polylactide-polyglycolide analysis analysis available
(2008) groups Parallel na Smoking Type of socket: acid Control: No

© 2011 John Wiley & Sons A/S

(10) groups 3 months habit: na na socket filling
follow-up Periodontal
status:
Periodontitis
Aimetti RCT Two 40 individuals Flapless Primary Test: Medical-grade calcium Reentry + stent Dimensions Italy Not
et al. study (na) Aged: closure: NO sulphate hemihydrate Control: changes: defect available
(2009) groups Parallel 51.27 Smoking Type of socket: No socket filling height (mm),
(11) groups 3 months habit: 0% na defect width
follow-up Periodontal (mm) Histological
status: na analysis
Crespi RCT Three 15 individuals Flapless Primary Test 1: Magnesium-enriched Periapical X rays Dimensions Italy Not
et al. study (na) Aged: closure: YES hydroxyapatite Test 2: Calcium changes: defect available
(2009) groups 51.3 Smoking (tissue graft) sulphate Control: No socket height (mm).
(12) Split mouth habit: 0% Type of socket: filling Radiological
3 months Periodontal 3-wall outcomes
follow-up status: na (no buccal wall) Histological
analysis
Casado RCT Four 19 individuals Flap Primary Test 1: bovine BMP + bOM Clinical + stent Dimensions: defect Brazil Not
et al. study (na) Aged: closure: YES Test width (mm) available
(2010) groups Split na Smoking Type of socket: 2: bovine BMP + bOM + absorbable Histological
(13) mouth 4 months habit: na na membrane Test 3: analysis
follow-up Periodontal absorbable membrane Control:
status: na No socket filling
Oghli & RCT Three 125 individuals Flapless Primary Test 1: Autogenous soft tissue Cast Dimensions Saudi
Steveling study (-14) Aged: na closure: YES (soft graft + collagen plug2 Test 2: changes: defect Arabia + Germany
(2010) groups Parallel Smoking habit: tissue graft) Autogenous soft tissue graft + height (mm) Not
(14) groups 3 months na Periodontal Type of socket: collagen matrix with available
follow-up status: na na gentamicin Control: No socket
filling

Abbreviations of the interventions: NA, data not available; RCT, randomized clinical trial; ACS, absorbable collagen sponge; e-PTFE, expanded polytetrafluoroethylene; BMP, bone morphogenetic pro-
tein; bOM, bovine organic matrix; CT scan, computerized tomography scanner; RhBMP, recombinant human BMP-2; FDBA, freeze-dried bone allograft; DFDBA, demineralized freeze-dried bone allo-

27 |
graft.

Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38

Vignoletti et al " Ridge preservation after tooth extraction
Vignoletti et al " Ridge preservation after tooth extraction

Table 2. Quality assessment of the articles included

Quality criteria

Adequate Incomplete Free of Free of

sequence Allocation outcome data selective other Risk of
# Author (year) generation? concealment? Blinding? addressed? reporting? bias? bias
1 Hoad-Reddick et al. (1994) c c 0 c a a High
2 Lekovic et al. (1997) c c 0 a a a High
3 Lekovic et al. (1998) a c 1 a a a High
4 Bolouri et al. (2001) b c 1 c a a High
5 Froum et al. (2002) c a 1 c a a High
6 Serino et al. (2003) b b b a a a Moderate
7 Iasella et al. (2003) b c 0 c a a High
8 Fiorellini et al. (2005) b b 2 a a a High
9 Barone et al. (2008) a c 1 a a a Moderate
10 Serino et al. (2008) b b b a a a Moderate
11 Aimetti et al. (2009) b c 1 c a a High
12 Crespi et al. (2009) b c 1 c a a High
13 Casado et al. (2010) c c 0 c a a High
14 Oghli & Steveling (2010) b c 0 a a a High

Abbreviations of the interventions: a: adequate explanation in the text; b: inadequate explanation in the text; c: not listed; 0: not blinded; 1: single-blinded;
2: double-blinded.

rone et al. 2008; Aimetti et al. 2009; Crespi Methods of measurement Study outcomes. Descriptive analyses of the
The changes in the primary outcomes were changes in the hard tissue dimensions
et al. 2009; Casado et al. 2010; Oghli & Ste-
assessed by clinical and radiographical Table 3a depicts the differences in the bone
veling 2010) elevated buccal and lingual mu-
examinations, as well as, by evaluation of crest height between baseline and the end of
coperiosteal flaps to perform the tooth
cast models. Hoad-Reddick et al. (1994), Fio- the investigations reported for test and con-
extraction and achieved primary closure,
rellini et al. (2005) and Crespi et al. (2009) trol groups. Eleven of 14 studies evaluated
except two studies that did not aim for pri-
used radiographs (orto-pantomography, CT the changes in the height of the bone crest
mary closure (Iasella et al. 2003; Serino et al.
scans, and periapical X-rays respectively). comparing the socket preservation therapy
2003; Serino et al. 2008) (Table 1). Flapless
Lekovic et al. (1998), Lekovic et al. (1997), with sockets left to heal spontaneously
extraction of the teeth was performed in four
Serino et al. (2003), Barone et al. (2008), Se- (Hoad-Reddick et al. 1994; Lekovic et al.
studies (Hoad-Reddick et al. 1994; Aimetti
rino et al. (2008) and Aimetti et al. (2009) 1997; Lekovic et al. 1998; Iasella et al. 2003;
et al. 2009; Crespi et al. 2009; Oghli & Ste-
assessed directly the bone changes at a re- Barone et al. 2008; Aimetti et al. 2009; Cres-
veling 2010) with two studies aiming to pri-
entry surgery. Within this group, four stud- pi et al. 2009). Overall, the control groups
mary closure through a soft tissue autograft
ies (Serino et al. 2003; Serino et al. 2008; demonstrated a mean vertical bone loss that
(Crespi et al. 2009; Oghli & Steveling 2010).
Barone et al. 2008; Aimetti et al. 2009) used ranged from !0.3 to !3.75 mm, whereas in
Four studies reported on the socket status
an acrylic stent to allow for reproducible the test groups, results were more heteroge-
after the extraction, with two studies report-
measurements, whereas two studies (Leko- neous demonstrating mean vertical bone
ing full integrity of the socket walls (Barone
vic et al. 1997; Lekovic et al. 1998) utilized changes ranging from !2.48 to 1.3 mm.
et al. 2008) or minimum buccal bone loss
titanium pins (Table 1). Two studies used Differences between test and control
(Froum et al. 2002) (<2 mm), whereas two
clinical measurements combined with groups, as reported by the authors, were
studies (Fiorellini et al. 2005; Crespi et al.
acrylic stents (Iasella et al. 2003; Casado statistically significant in four studies
2009) reported the absence of the buccal bone
et al. 2010), whereas other two (Lekovic included in the systematic review (Lekovic
wall.
et al. 1997; Oghli & Steveling 2010) et al. 1997; Lekovic et al. 1998; Iasella et al.
Different biomaterials were used in the
used cast models to evaluate the 2003; Fiorellini et al. 2005). Lekovic et al.
test groups of the studies included in the
dimensional changes between baseline and (1997) evaluated the ridge bone dimensional
review. Test treatment could be either graft
the end of the investigation. The most fre- changes at re-entry using titanium pins
alone (Hoad-Reddick et al. 1994; Lekovic
quent method was the mid-buccal measure- after GBR with e-PTFE membranes covering
et al. 1997; Lekovic et al. 1998; Bolouri et al.
ment. the socket walls in submerged healing or
2001; Froum et al. 2002; Iasella et al. 2003;
an untreated socket control. The same
Fiorellini et al. 2005; Barone et al. 2008; Ai-
research group used a similar experimental
metti et al. 2009; Crespi et al. 2009; Casado
Quality assessment
design to assess GBR with a biabsorbable
et al. 2010; Oghli & Steveling 2010) or mem-
Data from the quality assessment are membrane (Lekovic et al. 1998). Results
brane alone (Lekovic et al. 1997; Lekovic
reported in Table 2. All studies except one from both studies demonstrated statistically
et al. 1998; Casado et al. 2010), a combina-
randomized controlled trial (Barone et al. significant differences (P < 0.0005) in favour
tion of both (Iasella et al. 2003; Barone et al.
2008) and two controlled trials (Serino et al. of the GBR approach demonstrating a
2008; Casado et al. 2010) or a combination of
2003; Serino et al. 2008) were considered to greater vertical resorption in the control
graft and autogenous soft tissue graft (Crespi
have a high risk of bias. group.
et al. 2009 and Oghli & Steveling 2010).

28 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38 © 2011 John Wiley & Sons A/S

Iasella et al. (2003) with a similar design,
although evaluating the bone dimensional
changes at re-entry using an acrylic stent,
assessed the efficacy of filling the sockets
with freeze-dried bone allografts + tetracy-
cline and a collagen membrane in semi-sub-
merged healing. Differences with the
untreated control group were statistically
significant for the mid-buccal as well as
mesial and distal locations (P < 0.05), but not
for the mid-lingual locations.
Fiorellini et al. (2005) evaluated the ridge
height changes after therapy by computed
tomography reporting statistically significant
differences (P = 0.007) when comparing the
use of an absorbable collagen sponge (ACS)
soaked with 1.50 mg/ml rhBMP-2 with the
untreated control group.
Table 3b depicts the differences in the
width of the bone crest between baseline
and the end of the evaluation period
reported for test and control groups in eight
of the 14 studies (Lekovic et al. 1997; Leko-
vic et al. 1998; Iasella et al. 2003; Fiorellini
et al. 2005; Barone et al. 2008; Aimetti et al.
2009; Casado et al. 2010; Oghli & Steveling
2010). Overall, the control groups demon-
strated a mean horizontal bone loss that
ranged from !0.16 to !4.50 mm, whereas in
the test groups, results were more homoge-
neous demonstrating mean horizontal bone
changes ranging from 3.25 to !2.50 mm.
The differences between test and control
groups were statistically significant in five
studies.
Changes in soft tissue dimensions
Mean dimensional changes of soft tissues are
presented in Table 4. Two studies evaluated
the dimensional changes of the overall alveo-
lar ridge contour combining the changes of
hard and soft tissues (Lekovic et al. 1997; Og-
hli & Steveling 2010). Whereas Iasella et al.
(2003) evaluated the changes in gingival
thickness at different locations of the crest,
Lekovic et al. (1997) measured these changes
on cast models, both reporting significantly
less vertical and horizontal resorption in the
test group (P = 0.001). Oghli & Steveling
(2010), however, could not demonstrate dif-
ferences between using a collagen sponge
with/without gentamicine plus a circular soft
tissue graft to protect the wound, with the
untreated control socket (P = 0.07). Iasella
et al. (2003) also evaluated the gingival thick-
ness with an ultrasonic device at buccal and
lingual/palatal locations. Differences between
the ridge preservation therapy and the
untreated control were only statistically sig-
nificant for buccal sites.
© 2011 John Wiley & Sons A/S
Vignoletti et al " Ridge preservation after tooth extraction
Implant-related outcomes
Table 5 shows the studies with reported out-
comes on implant placement after tooth
extraction (Hoad-Reddick et al. 1994; Bolouri
et al. 2001; Froum et al. 2002; Iasella et al.
2003; Serino et al. 2003; Fiorellini et al. 2005;
Serino et al. 2008; Crespi et al. 2009; Aimetti
et al. 2009; Casado et al. 2010). Two studies
(Barone et al. 2008; Aimetti et al. 2009)
reported the placement of implants after 3
and >7 months without providing any details
on further soft or hard tissues augmentation
procedures. Two studies (Serino et al. 2003;
Serino et al. 2008) reported the placement of
dental implants after 6 and 3 months of heal-
ing respectively, specifying that all implants
achieved good primary stability in both test
and control groups. In one study (Fiorellini
et al. 2005), implants were inserted after
4 months of healing and statistically signifi-
cant differences were reported in favour of
the test group 1 (ACS+ 1.50 mg/ml rhBMP-2)
when compared to test group 2 (ACS+
0.75 mg/ml rhBMP-2) and the control treat-
ment, in regards to the number of secondary
augmentation surgeries needed, although no
further details were provided in regards to
the number and type of these procedures. In
the test 1 sites, 56.25% demonstrated ade-
quate bone volume for implant placement,
whereas the corresponding figures in test 2
and control groups were 25% and 12.5%
respectively.
Histological outcomes
Nine studies evaluated histologically, the
type of bone healing after 3 to >7 months
from the tooth extraction. Biopsies were
taken using a trephine before the osteotomy
preparation for implants insertion. Serial
decalcified sections were analysed under light
microscopy for qualitative and quantitative
histo-morphometrical analysis. Fiorellini
et al. (2005) and Casado et al. (2010) provided
descriptive histological observations, whereas
Froum et al. (2002), Barone et al. (2008), Seri-
no et al. (2008), Aimetti et al. (2009) and
Crespi et al. (2009) calculated fractions of
bone mineral, connective tissue and residual
graft material at different apico-coronal levels
of the socket. Serino et al. (2003) described
the fraction of bone mineral, whereas Iasella
et al. (2003) evaluated fractions of cellular/
acellular and trabecular bone.
Meta-analysis
Nine of the 14 included studies reported sim-
ilar comparisons and could be grouped in the
meta-analyses (Figs 2 and 3). The primary
outcome variables, defined as bone dimen-
sional changes (height and width of alveolar
process) were analysed and compared
between the test (socket preservation ther-
apy) and control group (spontaneous socket
healing). None of the other secondary out-
come variables could be grouped in meta-
analysis.
Seven studies were grouped in the meta-
analysis for bone height as the outcome vari-
able (Fig. 2). Two studies Fiorellini et al.
(2005), Crespi et al. (2009) evaluated two dif-
ferent preservation procedures, consequently,
each test socket preservation procedure vs.
the control group was considered as an inde-
pendent study in the meta-analysis. As there
was a high heterogeneity among the studies
(I2 = 95.2%; Tau2 = 0.639; v2 P-value <0.001),
we selected the random effect model for the
statistical evaluation. A statistically signifi-
cant greater reduction in bone height for con-
trol groups was demonstrated when
compared to the test groups (WMD =
!1.47 mm; 95% CI [!1.982, !0.953]; P
< 0.001; heterogeneity: I2 = 13.1%; v2 P-
value = 0.314). Due to this high heterogene-
ity, several subgroup analyses were performed
based on the surgical protocol used for the
socket preservation (flapless/flapped, barrier
membrane/no membrane, primary intention
healing/no primary healing) and on the mea-
surement method utilized to evaluate the
morphological changes.
None of the subgroup analyses achieved a
non-significant heterogeneity value. A ten-
dency towards greater weighted mean differ-
ences in favour of the test groups was
observed with flapless surgical protocol, no
membrane, primary intention healing and
with use of X-rays as measurement method
(Table 6). The meta-regression analysis failed
to encounter statistically significant differ-
ences among subgroups (data not shown).
Seven studies were grouped in the meta-
analysis on bone width as outcome variable
(Fig. 3). In two studies, more than one test
group were evaluated in comparison with the
control, and therefore they were considered
as independent (Serino et al. 2008; Oghli &
Steveling 2010). Also one study presented
data measured with two different outcome
measurements (cast models and re-entry sur-
gery) and they were also included indepen-
dently in the analyses (Lekovic et al. 1997).
As there was a high heterogeneity detected
among studies (I2 = 99.0%; Tau2 = 2.997; v2
P-value <0.001), the random effect model was
selected for the analysis. The results showed
a statistically significant greater reduction in
bone width for control groups when
compared to the socket preservation thera-
29 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38
30 |
Table 3a. Outcome variables: changes in bone height, expressed as mean (mm)
Vertical changes of the alveolar crest

Measurement
Publication (#) Interventions/groups method Surgical considerations Control Test Diff. P-value
Hoad-Reddick Test: Hydroxyapatite granules Control: No Lateral Flapless Primary closure: NO Type 2.42 0.65 ND:1.77 NA
et al. (1994) (1) socket filling cephalographs and of socket: NA
dental
pantomograms
Lekovic et al. Test: ePTFE® membrane Control: No Reentry surgery Flap Primary closure: YES Type of !1.2 !0.5 Mb: !0.7 0.001
(1997); _1 (2) socket filling socket: NA
Lekovic et al. Test: membrane of glycolide and lactide Reentry surgery Flap Primary closure: YES Type of !1.5 !0.38 Mb: !1.12 <0.0005
(1998) (3) polimers Control: No socket filling socket: NA
Serino et al. (2003) (6) Test: Sponge of polylactide–polyglycolide Reentry surgery + Flap Primary closure: YES Type of !0.8 1.3 Mb: !2.1 NA
acid Control: No socket filling stent socket: NA

Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38

Iasella et al. (2003) (7) Test: FDBA + tetracycline + collagen Clinical + stent Flap Primary closure: NO Type of !0.9 1.3 Mb: !2.2 <0.05
mombrane Control: No socket filling socket: NA
Vignoletti et al " Ridge preservation after tooth extraction

Fiorellini et al. Test 1: 0.75 mg/ml rhBMP/ACS Control: CT scan Flap Primary closure: YES Type of !1.17 !0.62 ND: !0.55 NS
(2005)_1 (8) No socket filling socket: 3-wall (no buccal wall)
Fiorellini et al. Test 2: 1.50 mg/ml rhBMP/ACS Control: CT scan Flap Primary closure: YES Type of !1.17 !0.02 ND: !1.15 0.007
(2005)_2 (8) No socket filling socket: 3-wall (no buccal wall)
Barone et al. (2008) Test: Corticocancellous porcine bone + Reentry + stent Flap Primary closure: YES Type of !3.6 !0.7 Mb: !2.9 NA
(9) collagen membrane Control: No socket socket: 4-wall
filling
Barone et al. (2008) Test: Corticocancellous porcine bone + Reentry + stent Flap Primary closure: YES Type of !3.6 !0.7 Mb: !2.9 NA
(9) collagen membrane Control: No socket socket: 4-wall
filling
Aimetti et al. (2009) Test: Medical-grade calcium sulphate Reentry + stent Flapless Primary closure: NO Type !1.2 !0.5 Mb: !0.7 NA
(11) hemihydrate Control: No socket filling of socket: NA
Crespi et al. (2009)_1 Test 1: Magnesium-enriched Periapical X-rays Flapless Primary closure: YES !3.75 !0.48 ND: !3.27 NA
(12) hydroxyapatite Control: No socket filling (tissue graft) Type of socket:
3-wall(no buccal wall)
Crespi et al. (2009)_2 Test 2: Calcium sulphate Control: No Periapical X-rays Flapless Primary closure: YES !3.75 !2.48 ND: !1.27 NA
(12) socket filling (tissue graft) Type of socket:
3-wall(no buccal wall)

Abbreviations of the interventions: P-values of the statistical analysis of the intergroup differences in the changes between baseline and end of the study. SD of the means of the intergroup differences
in the changes between baseline and end of the study. NS, not statistically significant; NA, data not available; Mb, midbuccal; ND, not defined site; ACS, absorbable collagen sponge; RhBMP, recombi-
nant human BMP-2; e-PTFE, expanded polytetrafluoroethylene; FDBA, freeze-dried bone allograft.

© 2011 John Wiley & Sons A/S

 Table 3b. Outcome variables: changes in bone width, expressed as mean (mm)
Horizontal changes of the alveolar crest

Measurement
Publication (#) Interventions/groups method Surgical considerations Control Test Diff. P-value
®
Lekovic et al. (1997)_2 Test: ePTFE membrane Control: No Reentry surgery Flap Primary closure: YES Type of 0.002

© 2011 John Wiley & Sons A/S

!4.4 !1.8 !2.6
(2) socket filling socket: NA
Lekovic et al. (1998) Test: membrane of glycolide and lactide Reentry surgery Flap Primary closure: YES Type of !4.56 !1.31 !3.25 <0.00001
(3) polimers Control: No socket filling socket: NA
Iasella et al. (2003) (7) Test: FDBA + tetracycline + collagen Clinical + stent Flap Primary closure: NO Type of !2.6 !1.2 !1.4 <0.05
mombrane Control: No socket filling socket: NA
Fiorellini et al. Test 1: 0.75 mg/ml rhBMP/ACS Control: CT scan Flap Primary closure: YES Type of 0.57 1.76 !1.19 NS
(2005)_1 (8) No socket filling socket: 3-wall(no buccal wall)
Fiorellini et al. Test 2: 1.50 mg/ml rhBMP/ACS Control: CT scan Flap Primary closure: YES Type of 0.57 3.27 !2.7 0.000
(2005)_2 (8) No socket filling socket: 3-wall (no buccal wall)
Barone et al. (2008) Test: Corticocancellous porcine bone + Reentry + stent Flap Primary closure: YES Type of !4.5 !2.5 !2 NA
(9) collagen membrane Control: No socket socket: 4-wall
filling
Aimetti et al. (2009) Test: Medical-grade calcium sulphate Reentry + stent Flapless Primary closure: NO Type !3.2 !2 !1.2 NA
(11) hemihydrate Control: No socket filling of socket: NA
Casado et al. (2010)_1 Test 1: bovineBMP + bOM Control: No Clinical + stent Flap Primary closure: YES Type of !0.16 3.05 !3.21 NA
(13) socket filling socket: NA
Casado et al. (2010)_2 Test 2: bovineBMP+bOM+resorbable Clinical + stent Flap Primary closure: YES Type of !0.16 2.42 !2.58 NA
(13) membrane Control: No socket filling socket: NA
Casado et al. (2010)_3 Test 3: resorbable membrane Control: No Clinical + stent Flap Primary closure: YES Type of !0.16 2.9 !3.06 NA
(13) socket filling socket: NA
Oghli & Steveling Test 1: Autogenous soft tissue graft + Cast Flapless Primary closure: YES !0.3 !0.8 0.5 0.001
(2010)_1 (14) collagen plug2 Control: No socket filling (soft tissue graft) Type of socket:
NA
Oghli & Steveling Test 2: Autogenous soft tissue graft + Cast Flapless Primary closure: YES !0.3 !0.1 !0.2 0.07
(2010)_2 (14) collagen matrix with gentamicin Control: (soft tissue graft) Type of socket:
No socket filling NA

Abbreviations of the interventions: P-values of the statistical analysis of the intergroup differences in the changes between baseline and end of the study. NS, not statistically significant; NA, data not
available; bOM, bovine organic matrix.

31 |
Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38
Vignoletti et al " Ridge preservation after tooth extraction
Vignoletti et al " Ridge preservation after tooth extraction
Table 4. Outcome variables. Soft tissue changes
Soft tissue changes
Publication (#) Interventions/groups
Lekovic et al. Test: ePTFE®
(1997)_1 (2) membrane Control:
No socket filling
Iasella et al. Test: FDBA
(2003) (7) + tetracycline
+ collagen
mombrane Control:
No socket filling
Oghli & Steveling Test 1: Autogenous
(2010)_1 (14) soft tissue graft +
collagen plug2
Control: No socket
filling
Oghli & Steveling Test 2: Autogenous
(2010)_2 (14) soft tissue graft +
collagen matrix with
gentamicin
Control: No socket
filling
P-values of the statistical analysis of the intergroup differences in the changes between baseline and end of the study.
pies (WMD = !1.830 mm; 95% CI [!2.947,
!0.732]; P = 0.001; heterogeneity: I2 = 0%; v2
P-value = 0.837). Due to the high heterogene-
ity initially detected among the studies, sev-
eral subgroup analyses were performed. None
of the subgroup analyses achieved a non-sig-
nificant heterogeneity value for all groups. A
tendency towards greater weighted mean dif-
ferences in favour of test groups was observed
with the use of membranes, a flapped surgi-
cal protocol, primary intention healing and
with CT as outcome measurement (Table 7).
The meta-regression analyses demonstrated a
statistically significant difference only in the
flapless/flapped subgroup (meta-regression;
slope = 2.26; 95% CI [1.01; 3.51]; P = 0.003).
Publication bias and sensitivity analyses
No publication bias was detected for changes
in bone height (P = 0.352; Egger’s test), nor in
bone width (P = 0.357; Egger’s test). The sen-
sitivity analysis to assess the effect of indi-
vidual studies on the summary estimates of
the meta-analysis showed that the exclusion
of single studies did not substantially alter
any estimates. In terms of bone height
changes, the greater change in WMD could
be attributed to Crespi et al. (2009)
(!23.25%) (Table 8). In regards to bone
width, the sensitivity analyses identified
three potential studies as responsible for
most of the heterogeneity (Fiorellini et al.
[2005] [!10.49%], Lekovic et al. [1998]
32 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38
Measurement
method Surgical considerations
Cast Flap; primary closure: YES Type of
socket: NA Vertical
measurements
Flap; Primary closure: YES Type of
socket: NA Horizontal
measurements
Ultrasonic metre Flap Primary closure: NO Type of
socket: NA
Cast Flapless Primary closure: YES
(soft tissue graft) Type of socket:
NA Horizontal measurements
Cast Flapless Primary closure: YES
(soft tissue graft) Type of socket:
NA Horizontal measurements
[!11.46%] and Oghli & Steveling [2010]
[15.15% and 10.79%]) (Table 9).
Discussion
Socket preservation therapies have been pro-
posed with the aim of maintaining the hard
and soft tissue dimensions of the alveolar
ridge that are partially lost after tooth extrac-
tion as part of the natural physiological heal-
ing process. This objective is particularly
pursued in preparation for dental implant
installation to have the best bone avail-
ability for successful implant prosthesis
(Tarnow & Eskow 1996). Unfortunately,
there are very few well-designed clinical
studies evaluating the efficacy of these thera-
peutic procedures and the potential benefit of
the different techniques/materials used is
still debatable.
The present systematic review seeks to
provide scientific evidence on the existing
RCTs and CTs evaluating different surgical
protocols aimed for preserving the bone of
the alveolar ridge after tooth extraction. The
primary outcome variables selected were the
vertical and horizontal hard and soft tissue
dimensional changes of the bone crest at
least 3 months after the tooth extraction.
Overall, the results from the meta-analysis
demonstrated statistically significant higher
alveolar bone crest preservation in both
Control Test Diff. P-value
!1 !0.2 Mb: !0.8 0.001
!4.2 !1.8 !2.4 0.001
0.4 !0.1 0.5 <0.05
!0.3 !0.8 0.5 0.001
!0.3 !0.1 !0.2 0.07
height and width in the test groups (interven-
tions for ridge preservation) when compared
with the healing of the untreated control
socket. In regards to the changes in bone
height, the overall WMD difference between
test and control groups amounted to
1.47 mm. Hence, the results from the meta-
analysis suggest that the use of socket preser-
vation therapies limits the dimensional
changes (vertical and horizontal) of the alveo-
lar ridge after tooth extraction. These data
are in agreement with a recent similar sys-
tematic review also assessing the influence
and potential benefit of socket preservation
procedures after tooth extraction in non-
molar regions of the mouth (Ten Heggeler
et al. 2010). These authors concluded, how-
ever, that although a benefit of such tech-
niques could be observed, vertical and
horizontal bone loss can be expected.
These results must be evaluated with cau-
tion as the quality assessment of the selected
studies demonstrated that all but two studies
(Barone et al. 2008; Serino et al. 2008) had a
high potential risk of bias. Furthermore, the
use of different biomaterials and surgical
techniques has been combined in this meta-
analysis, as well as the use of different types
of sockets (single/multiple, position in the
mouth and number of residual bony walls),
different reason of tooth extraction and differ-
ent methods of evaluation. This lack of con-
© 2011 John Wiley & Sons A/S
 Table 5. Implant-related outcomes
Implant-related outcomes

Secondary
Implant Time after augmentation
Publication Interventions/groups placement extraction Control Test surgery Histology Restoration

© 2011 John Wiley & Sons A/S

Hoad-Reddick et al. Test: Hydroxyapatite granules Control: No No – – – – No NA
(1994) (1) socket filling
Bolouri et al. (2001) Test: Bioplant HTR Control: No socket No – – – – No NA
(4) filling
Froum et al. (2002) (5) Test 1: Bioactive glass Test 2: DFDBA No – – – – Yes NA
Control: No socket filling
Serino et al. (2003) (6) Test: Sponge of polylactide–polyglycolide Yes 6 months All sites All sites NA Yes NA
acid Control: No socket filling
Iasella et al. (2003) (7) Test: FDBA + tetracycline + collagen Yes 4–6 months – – – Yes NA
mombrane Control: No socket filling
Fiorellini et al. (2005) Test 1: 0.75 mg/ml rhBMP/ACS Control: Yes 4 months Yes Yes 10 Yes NA
_1 (8) No socket filling 12.5% adequate 25% adequate
bone volume bone volume
Fiorellini et al. (2005) Test 2: 1.50 mg/ml rhBMP/ACS Control: Yes 4 months Yes Yes 56.25% 3 P < 0.05 NA
_2 (8) No socket filling 12.5% adequate bone test 1 vs. test
adequate volume 2 and control (11)
bone volume
Barone et al. (2008) Test: Corticocancellous porcine bone + Yes >7 months NA NA NA Yes NA
(9) collagen membrane Control: No socket
filling
Serino et al. (2008) Test: Sponge of polylactide–polyglycolide Yes 3 months All sites All sites NA Yes NA
(10) acid Control: No socket filling
Aimetti et al. (2009) Test: Medical-grade calcium sulphate Yes 3 months NA NA NA Yes NA
(11) hemihydrate Control: No socket filling
Crespi et al. (2009) Test 1: Magnesium-enriched Yes 3 months – – Yes NA
(12) hydroxyapatite Test 2: Calcium
sulphate Control: No socket filling
Casado et al. (2010) Test 1: bovineBMP + bOM Test 2: No – – – – Yes NA
(13) bovineBMP + bOM + resorbable
membrane Test 3: resorbable

33 |
membrane Control: No socket filling

Abbreviations of the interventions: NA, data not available; RCT, randomized clinical trial; ACS, absorbable collagen sponge; e-PTFE, expanded polytetrafluoroethylene; BMP, bone morphogenetic pro-
tein; bOM, bovine organic matrix; CT scan, computerized tomography scanner; RhBMP, recombinant human BMP-2; FDBA, freeze-dried bone allograft; DFDBA, demineralized freeze-dried bone allo-
graft.

Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38

Vignoletti et al " Ridge preservation after tooth extraction
Vignoletti et al " Ridge preservation after tooth extraction

Fig. 2. Meta-analysis: changes in bone height.

Fig. 3. Meta-analysis: changes in bone width.

sistency and standardization, in spite of the In fact, in terms of vertical bone height magnesium-enriched hydroxyapatite com-
lack of publication bias, may have contrib- changes, 23.25% of this effect was attributed bined with the closing of the socket with a
uted to the high heterogeneity of the results. to the study by Crespi et al. (2009) utilizing soft tissue autograft. This individual study,

34 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38 © 2011 John Wiley & Sons A/S
 Vignoletti et al " Ridge preservation after tooth extraction

Table 6. Meta-analyses by subgroups for changes in bone height reporting mean differences between test and
WMD 95% CI P-value I-squared control groups of 3.27 mm, however, only
Membrane selected sockets without full integrity of
(a) No !1.511 !2.583; !0.440 0.006 95.2% their bone walls, usually lacking the buccal
(b) Yes !1.192 !1.589; !0.834 0.000 87.9% cortical bone. This negative prognostic factor
Flap
for bone regeneration during undisturbed
(a) No !1.756 !3.400; !0.112 0.036 97.6%
(b)Yes !1.179 !1.516; !0.842 0.000 81.7% socket healing may in part, have contributed
Primary closure to the bigger effect of the socket preservation
(a) No !1.293 !2.730; 0.145 0.078 72.4%* therapy, compared with the other studies
(b) Yes !1.506 !2.077; !0.935 0.000 96.1%
Outcome variable
included in the meta-analysis. Likewise, in
(a) Reentry + stent !1.861 !3.606; !0.386 0.013 89.3% regards to the changes in bone width, three
(b) X-rays !2.276 !4.236; !0.316 0.023 97.9% studies provided the bigger heterogeneity in
(c) CT !0.866 !1.453; !0.279 0.004 14.5%
the meta-analysis, contributing to 15.15%,
(d) Clinical (stent) !2.200 !3.649; !0.751 0.003 NA
(e) Cast !0.800 !1.039; !0.561 0.000 NA 11.46% and 10.49% of the overall change
(f) Reentry surgery !0.912 !1.324; !0.501 0.000 90.6 respectively (Lekovic et al. 1998; Fiorellini
NA, not applicable, as only one study was included in the subgroup.
et al. 2005; Oghli & Steveling 2010). In par-
*
Non-statistically significant differences. ticular, on the negative effect side, Oghli &
Steveling (2010) that utilized a collagen
sponge as socket filler reported a higher bone
horizontal resorption in the test group. Apart
from the null efficacy of the filler used, the
Table 7. Meta-analyses by subgroups for changes in bone width
fact that cast models were used to measure
WMD 95% CI P-value I-squared these horizontal changes may have prevented
Membrane an accurate evaluation of the true dimen-
(a) No !0.982 !1.738; !0.227 0.011 93.3% sions of the alveolar crest. In contrast, Fiorel-
(b) Yes !2.465 !3.074; !1.856 0.000 86.6%
Flap lini et al. (2005) observed a difference of
(a) No !0.148 !0.788; 0.492 0.650 92.6% 3.85 mm in bone width when comparing the
(b)Yes !2.563 !3.101; !2.795 0.000 81.2% use of 1.50 mg/ml rhBMP/ACS vs. the con-
Primary closure
trol socket.
(a) No !1.263 !2.049; !0.478 0.002 0%
(b) Yes !1.968 !3.217; !0.732 0.002 99.2% The factors that may have contributed to
Outcome variable the obtained outcomes may be categorized
(a) Reentry + stent !1.682 !2.449; !0.914 0.000 47.0%* as: (1) the clinical conditions of the socket
(b) CT !3.026 !4.501; !1.551 0.000 52.3%*
(c) Clinical (stent) !1.400 !2.797; !0.003 0.050 NA
site, i.e. integrity/non-integrity of the socket
(d) Cast !0.682 !1.841; 0.476 0.248 98.4% bone walls, dimension and presence/absence
(e) Reentry surgery !2.986 !3.612; !2.361 0.000 76.2% of adjacent teeth; (2) the surgical protocol uti-
CT, computerized tomography; NA, not applicable, as only one study was included in the subgroup. lized, i.e. flapped/flapless surgery or primary
*
Non-statistically significant differences. flap closure/secondary intention healing; (3)
the biomaterial used, i.e. membrane/no
membrane, type of graft material and (4) the
type of evaluation method utilized. In an
attempt to assess the influence of each of
Table 8. Sensitivity analyses of the outcome variable bone heigth changes made with random
effect model these factors, a subgroup analysis was per-
Random estimation Heterogeneity formed, as well as meta-regression. The sub-
group analysis of flapped/flapless surgery
Study omitted WMD 95% CI WMD change (%) I-squared (%) P-value
demonstrated a minor influence in the verti-
Aimetti (2009) !1.55 !2.10; !1.00 5.70 12.44 0.328 cal resorption process, although it showed a
Barone (2008) !1.34 !1.86; !0.82 !8.70 4.85 0.396
significant difference in favour of the flapped
Crespi_1 (2009) !1.13 !1.41; !0.84 !23.25 49.25 0.038
Crespi_2 (2009) !1.49 !2.05; !0.93 1.69 16.14 0.295 group in regards to the ridge horizontal
Fiorellini_1 (2005) !1.55 !2.10; !1.01 5.93 12.6 0.327 dimensional changes. When comparing the
Fiorellini_2 (2005) !1.50 !2.05; !0.95 2.18 19.07 0.268 relative efficacy of using barrier membranes
Iasella (2003) !1.42 !1.95; !0.89 !3.07 18.87 0.269
Lekovic_1 (1997) !1.55 !2.15; !0.96 5.83 0 0.447 and/or grafts, while the use of membranes
Lekovic_2 (1997) !1.57 !2.17; !0.96 6.69 0 0.465 alone reported more vertical bone change
Lekovic (1998) !1.52 !2.19; !0.86 3.89 0 0.561 than the use of grafts alone, membranes
Serino (2003) !1.42 !1.95; !0.89 !3.27 19.07 0.268
obtained better results than grafts (either
None !1.47 !1.98; !0.95 0 13.71 0.314
alone or the combination of membrane and
Crespi_1: Magnesium-enriched hydroxyapatite vs. no socket filling. graft) in terms of horizontal bone changes.
Crespi_2: Calcium sulphate vs. no socket filling.
Fiorellini_1: 0.75 mg/ml rhBMP/ACS vs. no socket filling.
The subgroup analysis to assess the influence
Fiorellini_2: 1.5 mg/ml rhBMP/ACS vs. no socket filling. of flap closure demonstrated a slight ten-
Lekovic_1: outcome measured in cast model. dency towards less bone loss in the horizon-
Lekovic_2: outcome measured in reentry surgery.
tal direction when the sockets healed by

© 2011 John Wiley & Sons A/S 35 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38
Vignoletti et al " Ridge preservation after tooth extraction

Table 9. Sensitivity analyses of the outcome variable bone width made with random effect model of the location and the thickness of the
Random estimation Heterogeneity socket walls in the ensuing modelling and
WMD remodelling processes after tooth extraction
Study omitted WMD 95% CI change (%) I-squared (%) P-value
(Ferrus et al. 2010; Januario et al. 2011).
Aimetti (2009) !1.91 !3.09; !0.73 3.84 0 0.785 One major limitation of this systematic
Barone (2008) !1.82 !3.01; !0.63 !0.94 0 0.780
Fiorellini_1 (2005) !1.79 !2.96; !0.62 !2.71 0 0.773
review is that no meta-analyses could be per-
Fiorellini_2 (2005) !1.65 !2.80; !0.49 !10.49 0 0.875 formed on implant-related outcomes, due to
Iasella (2003) !1.88 !3.05; !0.72 !2.41 0 0.772 the lack of sufficient data. This fact is impor-
Lekovic_1 (1997) !1.77 !2.97; !0.58 !3.47 0 0.797
tant as there is no clear evidence that the
Lekovic_2 (1997) !1.75 !2.93; !0.57 !4.73 0 0.792
Lekovic (1998) !1.63 !2.46; !0.80 !11.46 0 0.381 occurrence of bone resorption after tooth
Oghli_1 (2010) !2.12 !3.35; !0.88 15.15 0 0.953 extraction may significantly limit the place-
Oghli_2 (2010) !2.04 !3.31; 0.77 10.79 0 0.903 ment of dental implants. In fact, one study
None !1.84 !2.95; !0.73 0 0 0.837
(Serino et al. 2008) reported that implants
WMD, weighted mean differences; CI, confidence interval. could be placed in all patients independently
Fiorellini_1: 0.75 mg/ml rhBMP/ACS vs. no socket filling.
of the group of treatment. The positive influ-
Fiorellini_2: 1.5 mg/ml rhBMP/ACS vs. no socket filling.
Lekovic_1: outcome measured in cast model. ence of the socket preservation therapy may
Lekovic_2: outcome measured in reentry surgery. be attributed more to achieving enhanced
Oghli_1: autogenous soft tissue graft + collagen plug vs. no socket filling. restorative and aesthetic outcomes, as well
Oghli_2: autogenous soft tissue graft + collagen matriz with gentamicin vs. no socket filling.
as better maintenance of healthy peri-
implant soft tissues. These possible influ-
ences were not evaluated in the reviewed
studies. Only one study assessed the possible
primary intention. In terms of the evaluation alveolar ridge after tooth extraction with a
influence of the socket preservation therapy
methods used, only the radiographic evalua- flapless approach (Fickl et al. 2008a, 2008b)
on the need of further augmentation thera-
tion demonstrated significant vertical (X- or when using socket preservation procedures
pies and in fact, the test group reported
ray) and horizontal (CT) changes when com- (Fickl et al. 2008a, 2008b; Blanco et al. 2010)
reduced needs of bone augmentation (Fiorel-
paring test and control groups. The use of and when placing implants immediately after
lini et al. 2005).
cast models and re-entry procedures was not the tooth extraction (Blanco et al. 2010).
In conclusion, the results from this sys-
able to demonstrate such significant differ- Other studies with a similar experimental
tematic review and meta-analysis have
ences. design, however, have failed to encounter sig-
shown that although some degree of bone
The results of the meta-regression analysis nificant bone dimensional differences
modelling and remodelling will occur after
showed that the surgical procedure (flapped/ between flapped and flapless tooth extrac-
tooth extraction, different ridge preservation
flapless) was the most important factor influ- tions (Araujo & Lindhe 2009).
procedures resulted in significantly less verti-
encing the results. Flapped surgical proce- The changes in the horizontal dimension
cal and horizontal contraction of the alveolar
dures demonstrated a significantly lesser have been the ones benefited most by the
bone crest. The obtained results, however,
horizontal resorption of the socket, when socket preservation techniques evaluated in
could not indicate which is the type of surgi-
compared to flapless surgeries (meta-regres- this systematic review. Precisely bone loss in
cal procedure or biomaterial most suitable
sion; slope = 2.26; 95% CI [1.01; 3.51]; a horizontal dimension is the most important
for this clinical indication, although the use
P = 0.003). These results may be due to the consequence of tooth extraction during the
of barrier membranes, a flap surgical proce-
importance of achieving full closure and first first 3–6 months of healing (Schropp et al.
dure and full flap closure demonstrated bet-
intention healing, mainly when the socket is 2003). In this meta-analysis, the bone hori-
ter results. There are limited data, however,
filled with a biomaterial or covered with a zontal changes in the control group were het-
on the possible influence of these therapies
barrier membrane. The effect of raising a flap erogeneous, ranging from !0.16 to
on the long-term outcomes of implant ther-
on the healing process of the socket after !4.50 mm. These differences may be due to
apy.
tooth extraction is still controversial with different factors, such as the socket location
results from experimental models reporting and the thickness of the socket walls. Recent
less pronounced bone remodelling of the studies in humans have shown the influence

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38 | Clin. Oral Impl. Res. 23(Suppl. 5), 2012/22–38 © 2011 John Wiley & Sons A/S
 I Workshop BQDC Octubre 2013

Protocolo de Preservación del Alveolo

José Nart e Ignacio Sanz

El proceso alveolar es una estructura dependiente de los dientes que se

desarrolla durante la erupción dental. El volumen y la forma del proceso
alveolar están determinados por la forma del diente, su eje de erupción
e inclinación (Schroeder et al. 1986).

La pérdida dental conlleva una pérdida de volumen en sentido

horizontal y vertical resultando en un reborde alveolar más estrecho y
más corto. Debido a que la cicatrización natural está asociada a una
pérdida de volumen de hasta el 50% durante el primer año, las técnicas
de preservación alveolar tienen como objetivo minimizar los cambios
volumétricos que se producen en los procesos alveolares con la
utilización de materiales de relleno óseo (van der Weijden et al. 2009).
El objetivo de esta revisión es conocer los resultados clínicos de la
técnica de preservación alveolar, las distintas variantes de la técnica
quirúrgica, los materiales de relleno óseo que podemos utilizar y crear un
árbol de decisiones que nos facilite la toma decisiones en la clínica para
conseguir los mejores resultados para nuestros pacientes en función de
la literatura disponible.

CICATRIZACIÓN ALVEOLAR

El primer paso cuando aparece una técnica es conocer las mejoras que
puede aportar al protocolo que se considera estándar. Es por ello que
debemos conocer los cambios dimensionales que se producen cuando
extraemos un diente y dejamos cicatrizar el alveolo por si mismo.
• Cambios en sentido vertical: Los estudios con reentrada en
humanos han mostrado que se produce una pérdida vertical del
11 al 22% a los 6 meses de la extracción de un diente. Si lo
miramos en valores absolutos, esta pérdida es de 1,24 mm de
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media.
• Cambios en sentido horizontal: Los estudios con reentrada en
humanos han mostrado que se produce una pérdida horizontal
del 29 al 63%. En valores absolutos, la pérdida media es de 3.8
mm.
Si tenemos en cuenta que la mayor pérdida se produce en los primeros
3 meses y ésta continúa hasta los 6 meses, es importante conocer si
disponemos de alguna terapia que pueda contrarrestar estos cambios
volumétricos o, a lo sumo, limitarlos.

PRESERVACION ALVEOLAR
La técnica de preservación del alveolo consiste en rellenar el alveolo
que queda tras la extracción de un diente con algún tipo de injerto
óseo, tratando de disminuir la pérdida del hueso alveolar. Al tratarse de
una técnica que se sale de lo que podríamos considerar como el
estándar, es importante revisar los siguientes puntos: eficacia clínica en
cuanto reducción de la pérdida tridimensional del hueso, indicaciones y
contraindicaciones, variantes de la técnica, resultados histológicos y
beneficios que pueden obtener nuestros pacientes.
1. Preservación de alveolo Vs. Extracción convencional

La reabsorción de la cresta que se produce al extraer un diente puede

limitarse con la técnica de preservación alveolar, pero no se puede
prevenir al 100%.
De 7 estudios, 5 han demostrado una menor reabsorción
estadísticamente significativa en sentido horizontal y 6 de 8 estudios lo
han demostrado estos resultados positivos para la reabsorción en
sentido vertical.
Para valorar el beneficio clínico en términos absolutos, disponemos de
varias revisiones sistemáticas que han evaluado a nivel global en cuánto
podemos reducir la pérdida ósea que se produce tras la extracción al
preserval el alveolo. En los meta-ánalisis de la revisión sistemática de
Vignoletti et al. 2012, la preservación de alveolo reduce de manera
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significativa los cambios en los volúmenes óseos en sentido horizontal

(1.83 mm) y en sentido vertical (1.47 mm) en comparación a no realizar
la preservación tras la extracción. En otra revisión sistemática más
reciente (Orgeas et al. 2013) se mostró como la técnica de preservación
de alveolo es efectiva en reducir la reabsorción de hueso en sentido
horizontal (2.9mm) y vertical (0.9mm).
De estas revisiones podemos sacar además otras conclusiones, cómo
que la pérdida de hueso no sólo va a depender de la técnica
quirúrgica, sino también de la anatomía del alveolo. De este modo, se
ha demostrado que si las paredes óseas del alveolo son gruesas, se
reducen los cambios tridimensionales tras la extracción, sobre todo a
nivel de la tabla vestibular. Si tenemos en cuenta que la mayor parte de
las tablas vestibulares van a ser menores a 1 mm (Ferrus et al. 2010),
puede ser importante aplicar esta técnica en sectores estéticos para
limitar los cambios de volumen y, con ello, los problemas estéticos que
pueden acontecer tras la extracción.

2. Indicaciones y contraindicaciones

Indicaciones:
(i) Cuando los implantes inmediatos o tempranos no están
recomendados.
(ii) Cuando los pacientes no están disponibles para recibir un implante
inmediato o temprano (embarazo, vacaciones,…).
(iii) Cuando no se puede conseguir estabilidad primaria del implante
inmediato.
(iv) En pacientes adolescentes.
(v) Contorneado de la cresta para el tratamiento protésico
convencional.
(vi) El ratio coste/beneficio es positivo.
(vii) Reducción de la necesidad de realizar elevación del seno maxilar.
 I Workshop BQDC Octubre 2013

Contraindicación:
(i) Infecciones intralveolares que no se pueden controlar/eliminar.
(ii) Cuando el coste-beneficion para el paciente no sea justificable.

3. Técnica quirúrgica
Se ha demostrado que el uso de implantes dentales tras la extracción
de un diente no previene la reabsorción tridimensional de la cresta que
se produce cuando tras la exodoncia. Es por ello que hay que valorar
muy bien las indicaciones de los implantes inmediatos a la extracción.
Debido a esto, la preservación de la cresta alveolar puede suponer una
opción terapéutica alternativa a los implantes inmediatos en pacientes
con un alto riesgo de problemas estéticos.
Se han propuesto distintas modalidades quirúrgicas y distintos materiales
para rellenar el alveolo, entre las que destacan las siguientes:
(i) Cirugía sin elevación de colgajo, relleno del alveolo con algún
injerto óseo (hueso autólogo, hidroxiapatita enriquecida con
magnesio, matriz de hueso humano
desmineralizado/mineralizado y el mineral de hueso bovino
desproteinizado) y cierre del alveolo con injerto de tejido
blando autólogo (injerto libre de encía tipo punch o injerto de
tejido conectivo en sobre) o xenoinjerto (matriz de colágeno).
La indicación principal de esta técnica es para alveolos
íntegros que mantienen la totalidad de la tabla vestibular.

(ii) Cirugía sin elevación de colgajo, relleno del alveolo con algún
injerto óseo (hueso autólogo, hidroxiapatita enriquecida con
magnesio, matriz de hueso humano
desmineralizado/mineralizado y el mineral de hueso bovino
desproteinizado) y cierre del alveolo con una membrana
reabsorbible o no reabsorbibles. A esta técnica se le podría
añadir un injerto de tejido blando para proteger los materiales
de regeneración. De nuevo, la indicación principal de esta
técnica es para alveolos con una tabla vestibular íntegra.
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(iii) Cirugía con elevación de colgajo, relleno del alveolo con

algún injerto óseo (hueso autólogo, hidroxiapatita enriquecida
con magnesio, matriz de hueso humano
desmineralizado/mineralizado y el mineral de hueso bovino
desproteinizado), membrana barrera reabsorbibles o no
reabsorbibles para proteger al injerto y cierre con colgajos
desplazados o con un injerto de tejido blando adicional. La
indicación principal de esta técnica es alveolos que han
perdido parcialmente alguna de las tablas vestibular o
palatina.

En cuanto a la revisión de la literatura, el uso de sustitutos óseos

(hidroxiapatita enriquecida con magnesio, la matriz de hueso humano
desmineralizado/mineralizado y el mineral de hueso bovino
desproteinizado) junto a una membrana de colágeno ha mostrado ser
efectivo en minimizar los cambios volumétricos de la cresta que se
producen al extraer un diente y el uso únicamente de membranas
barrera mejora la cicatrización del alveolo.
Por otro lado se ha demostrado que obtenemos una mayor ganancia
ósea significativa en sentido horizontal cuando elevamos un colgajo y
colocamos una membrana barrera, lo que supone un mayor trauma
quirúrgico para el paciente y un mayor gasto económico, por lo que
hay que valorar muy bien el coste-beneficio de esta técnica.
Y en cuanto al papel del cierre por primera intención del alveolo, se ha
mostrado que el cubrir por completo el alveolo y el material de injerto
tienen un efecto limitado en la reducción de la reabsorción
tridimensional del hueso. Además, los injertos de tejido blando junto al
material de injerto no han mostrado ser factores claves para mejorar los
resultados de la técnica de preservación de alveolo.

Hoy por hoy, con la evidencia científica disponible, no podemos afirmar

que un injerto óseo en particular o una técnica quirúrgica concreta
 I Workshop BQDC Octubre 2013

sean superiores, por lo que resulta difícil establecer guías clínicas

concretas para la preservación de alveolo. No obstante, en un
apartado posterior proponemos un árbol de toma de decisiones que
nos puede ayudar a optimizar los resultados de la preservación y a
elegir las mejores indicaciones posibles.

4. Histología

A nivel histológico se han mostrado distintos grados de formación de

hueso. Lo más característico es que con algunos injertos se interfieren en
la cicatrización del alveolo y del hueso, retardándolas.
De 8 estudios analizados, 6 han demostrado que en el grupo de
preservación de alveolo hay mayor formación de hueso trabecular,
aunque con técnica, no siempre se promueve la formación de nuevo
hueso.
Además, el uso de xenoinjertos solo sirven como un andamio
(osteoconducción) y no estimulan la formación de nuevo hueso.

5. Beneficios
Cuando nosotros realizamos una técnica adicional al tratamiento
convencional (implante en cresta cicatrizada), lo que esperamos es no
sólo que se facilite la colocación del implante y que necesitemos una
menor regeneración ósea, si no que los resultados a largo plazo sean
mejores. Sin embargo, no disponemos de literatura que demuestre que
la preservación del alveolo mejore los resultados a largo plazo de los
implantes en comparación a los implantes inmediatos o a los colocados
en cresta cicatrizada.
Cabe destacar que de 4 estudios, 3 han demostrado que en el grupo
de preservación de alveolo se ha necesitado menos aumento óseo en
el momento de colocar los implantes.
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PROTOCOLO QUIRÚRGICO

INSTRUCCIONES POST-OPERATORIAS

Farmacoterapia: Hoy en día no tenemos evidencia de que los

antibióticos sistémicos sean necesarios en la técnica de preservación de
alveolo. En función del tipo de biomateriales que empleemos, podemos
considerar dar las siguientes pautas:

- Amoxicilina 500mg. 1 comprimido/8 horas. 8 días.

- Ibuprofeno 600 mg. 1 comprimido / 6-8 horas. 3-4 primeros días.
Alérgicos
- Azitromicina 500 mg. 1compr / 24h. 3 días
- Paracetamol 500mg. 1 compr/6-8 horas. 3-4 primeros días.

Instrucciones de higiene oral:

- Colutorio clorhexidina 0,2% o 0,12% durante 30 seg. 2 veces/día
14 días post-tratamiento.
- No cepillado en la zona durante 14 días. Tras dicho periodo, el
cepillado será suave y progresivamente el paciente realizará
su higiene con normalidad.