Australian Dental Journal 2008; 53: 11–21

REVIEW
doi:10.1111/j.1834-7819.2007.00008.x

Ridge preservation: what is it and when should it be

considered
I Darby,* S Chen,* R De Poi*
*School of Dental Science, The University of Melbourne, Victoria.

ABSTRACT
The resorption of bone following extraction may present a significant problem in implant and restorative dentistry. Ridge
preservation is a technique whereby the amount of bone loss is limited. This paper discusses the scientific literature
examining the healing post-extraction and ridge preserving techniques, primarily from the perspective of implant dentistry.
Some indications for ridge preservation and methods considered appropriate are discussed.
Key words: Extraction, bone resorption, grafting, membranes, implants.
Abbreviation: ePTFE = expanded polytetrafluoroethylene.
(Accepted for publication 26 March 2007.)

INTRODUCTION Internal changes

Prerequisites for successful implant therapy are inte- When a tooth is removed, there is haemorrhage
gration of the implant, ideal implant position and followed by formation of a blood clot that fills the
appropriate hard and soft tissue contours. These entire socket.2 With this is an inflammatory reaction
require sufficient alveolar bone volume and favourable that stimulates recruitment of cells to form granulation
ridge architecture coupled with an appropriate surgi- tissue. Within 48 to 72 hours after extraction the clot
cal technique. However, following extraction of teeth starts to breakdown as granulation tissue begins to
the alveolar ridge resorbs, the rate of which may vary infiltrate the clot especially at the base of the socket. By
between sites and subjects. This may result in four days the epithelium proliferates along the socket
inadequate bone volume and unfavourable ridge periphery and immature connective tissue is apparent.
architecture for dental implant placement (Figs 1 After seven days the granulation tissue has completely
and 2). infiltrated and replaced the clot. At this stage, osteoid is
The aim of this article is to discuss events evident at the base of the socket as uncalcified bone
following extraction and how these can be optimized spicules. Over the next 2–3 weeks (3–4 weeks after
to facilitate successful implant therapy. The same extraction) this begins to mineralize from the base of
principles may be applied to edentulous areas in the socket coronally. This is accompanied by continued
order to enhance aesthetic outcomes for fixed bridges re-epithelialization which completely covers the socket
and removable dentures. However, the primary focus by six weeks post-extraction. Further infill of bone
of this article is to improve the outcome of implant takes place with maximum radiographic density at
therapy. around 100 days.
A number of factors may affect the healing of
undisturbed sockets. The size of the socket is important
Events following an extraction
with wider sockets requiring more time to bridge the
Healing of an extraction socket is characterized by defect compared with narrower sockets; it takes longer
internal changes that lead to formation of bone within to completely form bone at molar sites compared to
the socket, and external changes that lead to loss of single-rooted sites. The sockets of teeth with horizontal
alveolar ridge width and height.1 bone loss heal more quickly as the lower level of the
ª 2008 Australian Dental Association 11
I Darby et al.

Pietrokovski4 in an examination of healed sockets in

dried skulls showed that, from the occlusal aspect, the
crest of the residual ridge shifts lingually, and from the
lateral aspect, the ridge formed a concavity or flattened
to form a wall running straight between the alveolar
crests of the adjacent remaining teeth. Earlier studies
have shown a wide variation between subjects in the
dimensional changes both clinically and radiographi-
cally following removal of teeth, characterized by very
rapid reduction in both height and width.5,6 More
recent studies by Lekovic et al.7,8 have shown that there
is greater loss of alveolar ridge width than height and
that some degree of loss was observed at all extraction
Fig 1. Favourable ridge dimensions for implant placement. sites. It has been suggested that this variability is due to
anatomic, prosthetic, metabolic, functional, genetic and
iatrogenic factors.9 The most rapid changes were found
in the early post-extraction period, from six months to
two years.10,11 In addition, Atwood and Coy11 showed
that there were differences in the rate of resorption
between maxillary and mandibular sites. They found
that the average change was four times greater in the
mandible than the maxilla. It should be noted that the
above studies were performed on edentulous subjects.
Schropp et al.1 studied the effect of a single tooth
extraction of premolar or molar teeth on bone healing
and soft tissue changes using clinical and radiographic
measurements as well as digital subtraction radiogra-
phy. They showed that major changes take place in the
12 months following an extraction with an average of
50 per cent reduction in the width of the alveolar ridge.
Fig 2. Unfavourable ridge dimensions for implant placement.
Two-thirds of this reduction occurred within the first
three months. This loss averaged between 5 and 7 mm
alveolar bone means less infill is required. It should be and was similar at all sites in the mouth. Importantly,
noted that bone does not regenerate to a level coronal most of the subjects did not wear a denture after
to the horizontal level of the bone crest or to the level of extraction. Immediately after tooth extraction the
the neighbouring teeth (i.e., 100 per cent socket fill does width of the ridge was an average of 12 mm (8.6–
not occur).1 16.5 mm) and 12 months later 5.9 mm (2.7–12.2 mm).
Given that a standard body implant requires a mini-
mum of 6–7 mm of bone dimension, many of these sites
External changes
would not be suitable for implant placement. The
A recent study by Araujo and Lindhe3 showed that in authors conclude it would be advantageous if this loss
the first eight weeks following extraction in a dog of bone dimension could be prevented.
model there is marked osteoclastic activity resulting in
the resorption of the buccal and lingual crestal walls.
Ridge preservation
They noted that the reduction of height was more
pronounced at the buccal wall and was accompanied by Ridge preservation is any procedure undertaken at the
a horizontal loss on both buccal and lingual walls. This time of or following an extraction that is designed to
is an important finding because an adequate width and minimize external resorption of the ridge and maximize
height of buccal bone is important for optimal implant bone formation within the socket. However, there are
aesthetics, and this study suggests that loss of buccal clinical situations where it is not advisable to undertake
bone may result in poorer, suboptimal aesthetics. ridge preservation at the time of extraction (e.g., in the
presence of acute infection). In these situations, preser-
vation of the ridge may be delayed by six to eight
Dimensional changes following an extraction
weeks. A recent consensus report suggested that
Resorption of the external buccal and lingual socket minimal dimensional change occurs within six to eight
walls results in a change in the dimensions of the ridge. weeks of an extraction.12 Some ridge preservation
12 ª 2008 Australian Dental Association
 Ridge preservation

techniques are based on the principles of guided

(a)
tissue ⁄ bone regeneration. Many procedures have been
suggested including minimally traumatic tooth extrac-
tion, soft and hard tissue grafting, concomitant use of
barrier membranes and immediate implant placement.

Minimally traumatic tooth extraction

Although tooth extraction is by necessity a traumatic
procedure, the application of appropriate instruments
with minimal force is recommended to limit damage to
the hard and soft tissues. Fine luxators or periotomes
can be inserted into the periodontal ligament to sever
the coronal fibre attachment, thereby loosening the
tooth until forceps can gently deliver the tooth from its (b)
socket (Figs 3a and 3b). Multi-rooted teeth can be
decoronated and the roots sectioned and extracted
individually to facilitate this procedure (Figs 4a

(a)

Fig 4. (a) Decoronation and sectioning of a molar for extraction.

(b) Appearance of socket after roots sectioned and removed
individually.

and 4b). Given the increasing acceptance of implant

therapy, it may be argued that all extractions should be
undertaken with as minimally traumatic a technique as
possible. Even if an implant is not planned at the time
of tooth removal, the site may subsequently be consid-
ered for implant placement.

Timing of extractions
The summary of the literature above shows that most
(b) resorption takes place within the first three months
after extraction. Therefore, if possible, the tooth should
be retained for as long as possible and the extraction
scheduled in accordance with the chosen time for
implant placement. A detailed discussion and classifi-
cation for timing of implant placement after tooth
extraction may be found in the proceedings of the
3rd ITI Consensus Conference.12,13 However, it is not
always possible to retain all teeth in this manner with
pain and infection often necessitating immediate
removal of the offending tooth.

Fig 3. (a) Use of a periotome to aid in the minimally traumatic Debridement and decortication of the socket
removal of an upper right central incisor. (b) Appearance of the socket
immediately following extraction using periotome and the forceps only Some studies recommend that the sockets be debrided
to lift the tooth out of its socket. to remove anything that may interfere with healing,
ª 2008 Australian Dental Association 13
I Darby et al.

whilst others suggest that a round bur should be used to However, there is a paucity of research evidence to
perforate the socket walls a number of times to allow support this technique.
greater access for blood vessels into the socket and any Mobilization of tissue can be a difficult procedure,
grafting material in an attempt to improve bony infill.14 but splitting the periosteum at the base of a flap is
Conversely, it has been shown in an experimental study fairly straightforward and as a result may be the
that retention of the periodontal ligament along the technique of choice. However, coronally advanced
socket walls facilitated retention of the clot during the flaps need to be undermined and advanced a relatively
early stages of wound healing.15 Thus, apart from great distance to completely cover an extraction
removal of chronically inflamed tissue and foreign socket. This may cause complications such as altering
materials, extensive debridement or perforation of the the mucogingival line and creating a shallow vestibule,
socket walls may not be required. either of which may require subsequent surgery to
correct.21 These problems may be avoided using a
subepithelial connective tissue graft taken by a win-
Coverage of the socket by soft tissue
dow or envelope procedure from the palate. This
The literature is divided over whether soft tissue requires an appropriate donor site and sufficient
coverage of the socket at the time of extraction is coverage by soft tissue around the extraction socket
necessary for optimum healing of the socket and to prevent necrosis of the graft in the initial phase of
aesthetics. Soft tissue coverage procedures may be healing. The question remains that these techniques
considered to retain, stabilize and protect grafting may increase soft tissue coverage, but do they result in
materials. It is a critical step when using non-resorbable increased bone fill when used on their own. Recent
membranes. Many techniques have been suggested and work by Araujo and Lindhe3 in a dog model showed
include displacing neighbouring tissue to cover the that this is not the case, a finding which may argue for
socket, such as coronal advancement of a buccal flap, a space filler to be placed in the socket or use of a
rotating grafts from tissue adjacent to cover the defect, membrane to maximize bone infill.
or using free gingival or subepithelial connective tissue
grafts.16–18 Alternatively, the site may be left for six to
Bone or bone-substitute grafts only
eight weeks to allow healing and regeneration of
mucosa over the socket. The added volume of soft Many grafting materials have been used and these
tissue at this stage may facilitate optimum closure over include autogenous bone, demineralized freeze-dried
the socket when ridge preservation procedures are bone allografts (DFDBA), xenografts, bioactive glass,
undertaken. In a similar manner, procedures allowing hydroxyapatite and calcium sulphate (Table 1).
spontaneous soft tissue proliferation could be consid- Autogenous bone is thought of as the ‘‘gold stan-
ered prior to extraction to increase soft tissue coverage, dard’’.22 Becker et al.22 compared demineralized freeze-
such as removing the crown and burying the remaining dried bone against autogenous bone in seven paired
root.19 The Bio-Col technique20 involves the placement sites finding that after three months new bone was
of an anorganic bovine bone graft (Bio-Oss) protected formed at sites where autogenous bone was placed, but
by a resorbable collagen sponge (Collaplug – see below) not in six of seven sites using DFDBA. Common sites
and then allowing spontaneous epithelialization of intra-orally to harvest autogenous bone are around the
the socket under a denture tooth or bridge pontic. surgical site, ascending ramus, chin and tuberosity.

Table 1. Summary of the studies quoted investigating ridge preservation using bone grafts only, membranes only or
a combination
Method used Authors Material(s) used Outcome

Bone Graft only Becker et al. 1994 Autogenous bone compared to DFDBA Little new bone formation around DFDBA
Artzi et al. 2000 Bio-Oss On average 82.3% bone infill
Nemcovsky & Serfaty 1996 Hydroxyapatite Predictable ridge preservation
Froum et al. 2002 DFDBA and Bioactive glass Biogran 60% infill, DFDBA 33% infill
Guarnieri et al. 2004 Calcium sulfate 100% bone infill
Camargo et al. 2000 Bioactive glass mixed calcium sulfate Of some benefit
Membranes only Lekovic et al. 1997 ePFTE Signif greater infill and bone height ⁄ width
preservation than untreated control
Lekovic et al. 1998 Resolut Signif greater infill and bone height ⁄ width
preservation than untreated control
Bone graft and Iasella et al. 2003 DFDBA and Bio-Mend Less ridge width loss and more bone infill
membrane than untreated control
Fowler et al. 2000 DFDBA and acelluar dermal graft No loss of ridge width or height

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 Ridge preservation

Post-surgery the patient may experience considerable vitality, a measure of new bone formation, with the
discomfort in the donor. control and DFDBA sites showing approximately
A study using DFDBA23 showed that DFDBA cannot 33 per cent. However, it should be noted that all sites
speed up bone formation. Both Becker et al.22 and were to receive implants, which suggests that there may
Froum et al.24 showed little new bone formed around be little benefit of using a graft material. The placement
DFDBA. It is not available in Australia, but it is often of calcium sulphate has been studied in a recent paper.
mentioned in studies from North America and included Guarnieri et al.27 placed calcium sulphate in 10
here for the sake of completeness. extraction sockets without a barrier membrane and
Recently, Artzi et al.25 used a common porous re-entered the sites at three months. The graft material
bovine bone graft (Bio-Oss) in 15 fresh extraction had readily resorbed with 100 per cent bone infill and
sockets, covering the graft with soft tissue and implants were able to be placed at all sites. It should be
re-entering nine months later. They reported that noted that there is again a general lack of studies
there was 82.3 per cent bone infill and all sites reporting on the use of calcium sulphate, with which
allowed ‘‘safe’’ insertion of fixtures. Histologic appear- the authors of the above paper concur. One study has
ance showed a mixture of Bio-Oss and new bone looked at the use of bioactive glass and calcium
formation, increasing in bone fraction apically. The sulphate together.28 No statistical difference was found
use of a xenograft does not require a donor site, thus between experimental and control groups, casting
reducing morbidity following harvesting and simplify- doubt on the use of these materials in combination.
ing the procedure. Figure 5 shows Bio-Oss placed in Another product that was used to graft extraction
an extraction socket. sockets is BioPlant HTRTM. It is a biocompatible
Hydroxyapatite use in fresh extraction sockets in a microporous composite of methacrylate and calcium
series of 23 cases was reported by Nemcovsky and hydroxide. Haris et al.29 reported that after a period of
Serfaty.26 They achieved primary closure by rotating 8 to 12 months there was sufficient hard tissue to
split thickness flaps and were followed for 24 months. place implants. More recently, biphasic calcium phos-
They showed that there was predictable ridge preser- phate has become available in Australia. This is a
vation with minimal postoperative ridge deformation combination of hydroxyapatite and tricalcium phos-
(1.4 mm vertically and 0.6 mm horizontally). This phate. However, the authors are not aware of any
would retain sufficient bone volume to allow implants peer-reviewed papers investigating its use in ridge
to be inserted. However, over half the patients experi- preservation.
enced some exfoliation of hydroxyapatite suggesting Except for the study by Guarnieri et al.27 in each of
that the flap design was not predictable in maintaining the above papers residual particles of the graft were
soft tissue closure. A bioactive glass (Biogran) was found at time of re-entry and raises the question of
investigated in fresh extraction sockets by Froum what effect this may have on implant placement. The
et al.24 and compared to control sockets and those evidence above may argue for use of calcium sulphate
with DFDBA. All sites were covered by flap advance- which resorbs completely, but as mentioned earlier
ment and re-entered six to eight months later. The there are few studies. Materials like Bio-Oss have been
placement of Biogran resulted in 60 per cent bone much more widely researched. However, the authors
feel that the question remains ‘‘Does it matter if
particles are left?’’. If most bone infill is along the
socket walls and base,25 then any remaining particles
may be removed during the osteotomy. However, in a
dog study of implants placed in sites three months after
grafting with Bio-Oss there was still a substantial
portion of the graft present, and no osseointegration
occurred to the implants within the augmented portion
of the crest.30 This paper reinforces the need to wait
six to eight months post-grafting before implant
placement.
These papers show many different techniques for
improving the bony healing in extraction sockets, but
fail to answer what is the clinical relevance. Can a
particular technique reproducibly achieve a level of
bone fill that allows implant placement and reduces
tissue loss to a minimum? The above reports only
Fig 5. Bio-Oss placed in an extraction socket for ridge preservation. It answer this question obliquely by indicating whether or
will require something to hold it in place. not implants were placed.
ª 2008 Australian Dental Association 15
I Darby et al.

Membranes only
It is also possible to cover the socket to prevent ingress
of soft tissue, thereby promoting maximal bony heal-
ing. Generally, there are two types of membrane used,
resorbable and non-resorbable. Table 1 summarizes the
papers quoted in this article. In 1997, Lekovic et al.7
investigated the use of a non-resorbable expanded
polytetrafluoroethylene (ePTFE) membrane to maintain
the alveolar ridge after extraction. Two sites each in 10
patients were used, one site receiving a membrane and
the other site as a control. All sockets were debrided
and flaps displaced to cover the membrane and socket.
Reassessment took place at six months, with signifi-
cantly greater loss of bone height and width in the
control group and more infill in the ePTFE group.
However, 30 per cent of membranes became exposed
and this resulted in similar results to the control group.
Giving the high rate of exposure, this paper suggests the
use of ePTFE membranes should perhaps be avoided.
Figure 6 shows the use of an ePTFE membrane.
A later paper by the same group8 looked at the use of Fig 7. Bio-Gide membrane used in ridge preservation. These
membranes usually require a bone graft in the socket to sufficient
a resorbable membrane compared to a control site in 16 support to prevent them collapsing into the socket.
patients. A polyglycolide ⁄ lactide membrane (Resolute,
WL Gore & Associates) was placed and reassessed at
resorbable membranes should be preferred over non-
six months. The experimental sites showed significantly
resorbable. Unfortunately, the authors did not report
less loss of alveolar bone height, more internal socket
on whether the ridges were suitable for implants
fill and less horizontal resorption of the ridge. Impor-
irrespective of technique, which limits the usefulness
tantly, there were no exposures. Therefore, it seems that
of these papers. Although an animal-derived mem-
brane, Bio-Gide is available in Australia and used
widely in clinical periodontal practice. We are unaware
of any ridge preservation studies reporting its use, but
there seems to be no reason why it could not be used
in this manner. Figure 7 shows the placement of a
Bio-Gide membrane.

Bone grafts and membranes together

Some studies have investigated the use of bone grafts
and membranes together (Table 1). Iasella et al.31
reported on the use of tetracycline hydrated freeze-dried
bone allograft and a resorbable membrane (Bio-Mend)
compared to extraction alone in 24 patients. They
replaced the flap without complete socket coverage and
reassessed four to six months later. Both groups lost
ridge width, although the experimental group lost less
width and had more bone infill. The test group sites
were more suitable for implant placement, but all sites
were still able to receive implants. In a case report,
Fowler et al.32 used DFDBA and an acellular dermal
graft for ridge preservation. An acellular dermal graft is
an allograft harvested surgically and with all cellular
material and epidermal layer removed. The authors
found the height of tissue to be acceptable for implant
Fig 6. ePTFE (Goretex) membrane in place. This later became
exposed, with consequent infection and soft and hard tissue loss. placement and suggested this technique be used
PTFE membrane intentionally left exposed and removed at 4–6 weeks. where primary closure couldnÕt be achieved. Recently,
16 ª 2008 Australian Dental Association
 Ridge preservation

however, the American Academy of Periodontology

(a)
(AAP) issued a notice describing the recall of one
particular brand due to incomplete medical information
regarding the origin of the graft.
Interestingly, Fugazzotto33 in a report on a compar-
ison of resorbable and titanium-reinforced membranes
used with Bio-Oss found that ‘‘significant bucco-lingual
ridge collapse was noted upon re-entry’’. The findings
of this paper are supported by the work of Zubillaga
et al.34 who showed that tacked membranes in place
results in less loss of augmented bone than non-tacked
membranes.

Other ‘‘space fillers’’ (b)

It appears that insertion of a filler material into the
socket is important to preserve as much bone as
possible, but does it always have to be a bone graft?
In addition, the presence of graft particles at time of
placement may not be desirable. Serino and co-work-
ers35 placed in 36 patients a commercially available
bioabsorbable sponge of polylactide-polyglycolide. The
teeth were surgically extracted, sockets debrided, the
sponge inserted and flaps replaced with no primary
closure. Six months later all sites were reassessed and
implants placed. There were 26 test sockets and 13
control. All test sockets healed with less bone resorp-
tion than the controls especially in the mid-buccal
region. The authors suggested that the sponge served as
a support to prevent the collapse of the surrounding
soft tissue into the socket during the healing process. A
similar product is available commercially in Australia
and is a collagen plug (Collaplug, Zimmer Dental). This
and the sponge above can be placed into the socket
(c)
without raising a flap, but there is little research in this
area and the materials may only act to stabilize the clot
and not to preserve the ridge. Figure 8a shows
Collaplug before it is placed, Fig 8b after placement
in the socket and Fig 8c demonstrates healing after
three weeks.

Implants as ridge preservers

The third ITI consensus report showed that immediate
implants are a very successful form of therapy.12
However, it has been reported that implants do not
‘‘preserve’’ the ridge they are placed into.36–38 Araujo
et al.36 demonstrated that immediate implant placement
in a dog model failed to prevent resorption of the socket
walls, especially buccally. They suggested that this may Fig 8. (a) Collaplug before placement. (b) Collaplug placed in an
extraction socket. It quickly soaks up blood and reduces in size.
be due in part to the early disappearance of the bundle (c) Healing after three weeks after Collaplug placement.
bone and also disruption of the blood supply buccally
due to elevation of a flap. Bundle bone, in the presence
of a tooth, occupies a larger fraction of the marginal ligament inserting. It seems that when a tooth is removed
portion of the bone wall in the buccal than lingual and bundle bone is resorbed rather than replaced. If one
has a large number of fibres from the periodontal thinks in terms of solely being able to place an implant
ª 2008 Australian Dental Association 17
I Darby et al.

then this may not matter at all as long as there is Although no one procedure or technique meets all of
enough bone initially, but this may cause problems the above criteria, a reasonable choice would seem to
later especially in aesthetic areas if there is buccal tissue be a surgical procedure involving placing an osteo-
loss.39 conductive bone graft with a slow resorption rate (Bio-
Oss or a synthetic material) covered with a resorbable
membrane which may be tacked into place. This
The future
appears to be a method that may preserve sufficient
Given the current advances in stem cell technology we volume and contour to permit subsequent implant
may in the future be able to place tooth buds in sockets placement and achievement of acceptable aesthetic
to regrow teeth or place a cellular scaffold in the socket results. Compared to the plugs this technique has been
to maintain the bone. Cultivated scaffolds from bone proven to provide adequate ridge height and width for
marrow mesenchymal stem cells have been placed implant placement.
into fresh extraction sockets with results that ‘‘show The authorsÕ recommendation is that if a ridge is to
promise’’.40 be preserved with predictable bone-fill, then a material
with osteoconductive properties and slow rate of
resorption (Bio-Oss or other synthetic material) should
Complications
be used. The socket should be sealed with a CT graft or
It needs to be mentioned that any surgical procedure the Bio-Col technique used to effect soft tissue closure.
may have complications. These commonly are post- The implant would then be placed four to six months
operative pain and swelling, and occasionally infection. later to provide sufficient time for maturation of the
Any surgery on the gingival tissues will cause some graft.
recession. It is well known that in GTR procedures If it is planned that the implant be placed within six
up to 70 per cent of non-resorbable membranes may to eight weeks of extraction, then techniques and
become exposed to the oral environment, severely materials designed to promote bone fill are not
reducing the amount of new tissue formed.41 In necessary. Instead, the authors would recommend using
addition, Girard et al.42 reported a case of a foreign a resorbable collagen sponge (Collaplug or other
body granuloma following placement of a graft into an similar material) to aid with initial clot stabilization,
extraction socket with pain and sensation disturbance. but the authors would not be relying on it to preserve
It should be noted that the site was already compro- the ridge.
mised by previous infection and may serve as a
reminder to debride sockets fully or not to undertake
Indications for ridge preservation
preservation in the presence of infection.
The review of the literature above shows that ridge
preservation should be considered if an implant is to
DISCUSSION
be placed more than six to eight weeks after tooth
Although the literature presents a confusing picture extraction. If an implant is to be placed at the time
with difficulty in comparing studies, ridge preservation of extraction or within six to eight weeks following
does appear to limit the loss of hard and soft tissue at extraction, there appears to be little benefit in carrying
extraction sites, and can provide less bone loss com- out ridge preservation procedures at the time of
pared to non-preserved sites. While there were extrac- extraction. Even when an implant might not be planned
tion-only sites that were suitable for implant therapy, in the near future, ridge preservation should be
the most predictable maintenance of ridge width, height considered in strategically important sites to retain the
and position was achieved using ridge preservation. possibility of an implant option for the patient in the
Ideally, a technique for socket preservation ought to be future. Ridge preservation should also be considered for
easy to use, not involve surgery, leave no residual aesthetic reasons at pontic sites in conventional fixed
foreign bone particles, involve no ‘‘floppy’’ membranes prosthodontics.
likely to collapse into the socket and result in no bone Figure 9 presents an outline of the questions that the
loss. However, it appears that no material or technique authors suggest should be asked at the time when
fully meets these criteria. extraction is considered and the suggested approaches
The authors experience with Collaplug (Zimmer) is that should followed. Specific indications for ridge
that, after six to eight weeks, resorption is similar to preservation include the following: (1) sites where the
that seen in a normal extraction socket; the material buccal plate is less than 1.5–2 mm thick (virtually
therefore does not seem to do much to preserve the always in the anterior and aesthetic zone) and sites
ridge. The PGA ⁄ PLA plug reported by Serino et al.35 where there has been damage or loss of one or more of
may have been designed to have a much slower the socket walls. These sites may lose a clinically
resorption rate. significant amount of the buccal plate upon healing3,42
18 ª 2008 Australian Dental Association
 Ridge preservation

Should the alveolar ridge be preserved? Is implant placement

being considered
within the next 6 to 8
weeks?

NO....Why no?
Is the site extremely compromised,
the buccal plate more than 2 mm NO.... there is significant
YES....Does the tooth damage to the socket walls, YES....is a graft required?
need to be extracted thick, bone volume does not have to
be maintained or have previous primary implant stability cannot
immediately? be assured or implant placement
extraction sites healed up well?
has to be delayed due to
scheduling problems NO.... the YES.... One or more
socket walls of the socket walls
Select a material that has a slow are intact and have been lost, and
rate of resorption and which will significant collapse of the ridge
No.....Try to keep the tooth until eventually form new bone resorption is needs to be
Yes......Is there anything time of implant therapy – anorganic bovine bone not minimized.
stopping placement of a ridge – bioactive glass anticipated in
preserving material, such as acute – biphasic calcium phosphate the following Select a material that
infection or medical issues? 6 to 8 weeks will rapidly resorb
Delay implant placement for 4 to – no graft – collagen plug
6 months required – calcium sulfate

No....Is it a surgical extraction?

Yes......Debride
socket as much Fig 10. Questions to be asked to assist with selection of an
as possible and appropriate material to be used for ridge preservation.
leave to heal.
Consider some
form of ridge
Yes.... consider the use If not then the next question is ‘‘Is there significant
preservation 6–8 No.... use a material
weeks later
of bone grafts and
that can be easily damage to the socket that prevents primary stability
membranes to promote
as much bone
contained in the socket and requires grafting?’’, which will not only require
to preserve the ridge
preservation as possible new bone formation, but the maintenance of as much
and to build out the
buccal plate. Also existing bone as possible. A slowly resorbing material
consider soft tissue which will support the tissues and eventually form bone
coverage of the socket
is the material of choice. If the implant will be placed
Fig 9. An evidence-based outline of the questions that should be asked
within six to eight weeks then we suggest that the
at the time when extraction is considered and suggested approaches following question should be ‘‘Is a graft required?’’.
that should followed. The answer will be in the negative if the socket walls
are intact and significant resorption is not anticipated.
However, if there has been damage, i.e., where one wall
and are more likely to present a challenge for successful has been lost and collapse of the ridge must be
implant therapy; (2) sites where maintaining bone minimized that a rapidly resorbing material could be
volume is crucial to minimize the risk of involving chosen.
anatomical structures, such as the posterior maxilla or Contraindications to ridge preservation are acute
mandible, where the maxillary sinus or inferior alveolar infection, where unassisted socket healing is likely to
nerve may present as a complication if further bone is result in good ridge morphology, when maintaining
lost; (3) a patient with high aesthetic demands, such as bone volume is not critical and where surgery is
a high lip line or a thin biotype, which is prone to more contraindicated by medical issues. The patient must
recession; and (4) in patients where many teeth are to consent to the procedure also, which will involve
be extracted and preservation of the bone is important explaining the source of all materials. There might be
of further restoration. religious and ethical issues with some of the materials
It should be noted that it is difficult to predict how (i.e., vegetarians and vegans with animal products).
sites will heal. Some sockets will heal without much
resorption, whereas others will lose a lot of hard and
Limitations
soft tissue. If the patient has had a number of previous
extractions then the loss of supporting ridge at these Ridge preservation has been developed recently. There
sites might provide an indication of what will happen. are a great number of techniques that have been
It appears that if there is any doubt about hard and soft presented, but with only few research reports to
tissue loss then one should try to preserve the ridge. support. Further long-term studies are required espe-
Figure 10 presents an outline of the questions we cially to assess the ridge dimension following preserva-
suggest that should be asked to assist with the selection tion and implant placement. From the studies reviewed
of materials, etc. The first consideration is timing of above there is no ideal technique to achieve 100
implant placement. Will it be within six to eight weeks per cent bone preservation every time. No one tech-
or will implant placement be delayed beyond this time? nique is appropriate for all situations and a flap might
ª 2008 Australian Dental Association 19
I Darby et al.

have to be raised in some cases. Much may depend on 13. Hämmerle CHF, Chen ST, Wilson TG. Consensus statements and
recommended clinical procedures regarding the placement of
the general health and habits of the patient, such as implants in extraction sockets. Int J Oral Maxillofac Implants
smoking. 2004;19(Suppl):26–28.
14. Buser D, Dula K, Belser U, Hirt HP, Berthold H. Localized ridge
augmentation using guided bone regeneration. I. Surgical proce-
CONCLUSIONS dure in the maxilla. Int J Periodontics Restorative Dent
1993;13:29–45.
Implant treatment can be facilitated at the time of
15. Cardaropoli G, Araujo M, Lindhe J. Dynamics of bone tissue
extraction by considering ridge preservation and main- formation in tooth extraction sites. An experimental study in
taining sufficient bone for optimal implant placement dogs. J Clin Periodontol 2003;30:809–818.
and consequently appearance. Consideration has been 16. Carmagnola D, Berglundh T, Lindhe J. The effect of a fibrin glue
given to healing of extraction sockets and previously on the integration of Bio-Oss with bone tissue. An experimental
study in labrador dogs. J Clin Periodontol 2002;29:377–383.
published studies that have attempted to preserve the
17. Misch CE, Dietsh-Misch F. A modified socket seal surgery with
alveolar ridge. Based on these studies the authors have composite graft approach. J Oral Implantol 1999;25:244–250.
designed an outline of the questions the authors feel 18. Landsberg CJ, Bichacho NA. A modified surgical ⁄ prosthetic
should be asked when considering ridge preservation. approach for optimal single implant supported crown. Part 1. The
This article also covers some of the materials available. socket seal surgery. Pract Periodontics Aesthet Dent 1994;6:11–
17.
The majority of teeth are extracted by general dental
19. Langer B. Spontaneous in situ gingival augmentation. Int J
practitioners and it is hoped that this article will Periodontics Restorative Dent 1994;14:524–535.
stimulate some thought on the topic of ridge preserva- 20. Sclar A. The Bio-Col technique. In: Bowyers LC, ed. Soft tissue
tion. Not all extraction sockets need to be preserved, and esthetic considerations in implant therapy. Chicago, IL:
but the authors feel that ridge preservation ought to be Quintessence, 2003:163–187.
considered at the time of tooth removal. 21. Seibert JS, Slama H. Alveolar ridge preservation and reconstruc-
tion. Periodontol 2000 1996;11:69–84.
22. Becker W, Becker BE, Caffesse R. A comparison of demineralized
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lowing immediate implant placement at extraction sites. J Clin Senior Lecturer and Head of Periodontics
Periodontol 2004;31:820–828. School of Dental Science
38. Chen ST, Darby IB, Adams GG, Reynolds EC. A prospective The University of Melbourne
clinical study of bone augmentation techniques at immediate
implants. Clin Oral Implants Res 2005;16:176–184. 720 Swanston Street
39. Araujo MG, Wennstrom JL, Lindhe J. Modeling of the buccal Parkville, Victoria 3010
and lingual bone walls of fresh extraction sites following Email: [email protected]

ª 2008 Australian Dental Association 21