Periodontology 2000, Vol. 68, 2015, 122–134 © 2015 John Wiley & Sons A/S.

& Sons A/S. Published by John Wiley & Sons Ltd

Printed in Singapore. All rights reserved PERIODONTOLOGY 2000

Alveolar socket healing: what can

we learn?

O , C L EV
M A U R I C I O G. A R A UJ ^ ICA MISAWA & FLAVIA

E R S O N O. S I L V A , M ON
SUKEKAVA

In current dentistry, the healing process of the Anatomic considerations

socket following tooth extraction has become an
important topic of research, study and discussion. The alveolar process may be defined as the bone tis-
The reason for this relies mainly on the fact that sue that surrounds a fully erupted tooth and it is
after tooth extraction several changes can occur in formed in harmony with the development and erup-
the alveolar process, which may prevent or render tion of the teeth (Fig. 1). It is limited coronally by the
difficult implant installation in a prosthetically dri- bone margins of the socket walls, whilst an imaginary
ven position (23). In addition, the increasing line that cuts the bottom of the socket in a perpendic-
demand for esthetics in dentistry highlights the ular direction to the long axis of the root, limits it api-
importance of maintaining adequate ridge volume cally. Beyond such a line, the basal bone of the
in order to achieve a long-term esthetically accept- mandible or the maxilla can be found.
able implant-support prosthesis (42). Thus, it is The morphologic characteristics of the alveolar
increasingly expected that the results of the healing process are related to: (i) the size and shape of the
process should promote the formation of an alveo- tooth; (ii) the site of tooth eruption; and (iii) the incli-
lar ridge with a sufficient volume of hard and soft nation of the erupted tooth. In general, teeth tend to
tissues to allow an ideal implant-supported restor- erupt and incline to a position outside the center of
ative outcome. the basal bone (62). In a recent clinical study, Janua-
Tooth extraction was once described as a tissue rio et al. (46) described some of the morphological
amputation that may lead to functional, psychologi-
cal, postural and local changes (14). Indeed, tooth
extraction is initially perceived purely as tooth loss,
but local changes arise and promote hard- and
soft-tissue alterations. The process of local changes
that take place in order to close the wound and
restore tissue homeostasis is called “socket healing”.
Thus, the aims of the present review were two-fold:
first, to describe the socket-healing process; and, sec-
ond, to discuss what is to be learned from that healing
process that may improve the treatment outcome.

The alveolar process

In order to understand the socket-healing process
and its clinical implications, it is pivotal to know the
characteristics of the tissues that comprise the alveo-
lar process. Thus, a brief anatomic and histologic
Fig. 1. Cone-beam tomographic image representing the
description of such tissues is provided below (for alveolar process at the maxillary lateral incisor region. The
detailed review, see 7, 65). alveolar process is the bone that surrounds the root.

122
 Alveolar socket healing

features of the alveolar process in the anterior maxilla thickness at the anterior front tooth region. Thus,
in humans. The authors included 250 periodontally most of the thin buccal bone wall is a tooth-depen-
healthy subjects, 17–66 years of age. Cone beam com- dent structure (Fig. 3).
puted tomograms were obtained from the maxillary
front teeth. Measurements of the thickness of the
buccal bone plate of the alveolar process were per- Socket healing
formed at three different positions in relation to the
buccal bone crest (i.e. at distances of 1, 3 and 5 mm
Dimensional changes
apical to the crest). The measurements demonstrated
that the buccal bone plate in most locations, in all The dimensional changes that occur in the alveolar
anterior tooth sites examined, was ≤1 mm thick (aver- ridge following tooth extraction have been reported
age thickness ~0.5 mm) and that close to 50% of sites in several human studies (14, 16, 47, 48, 62, 63, 66, 74)
had a bone plate thickness that was ≤0.5 mm. In con- and were determined using different methodologies,
clusion, tooth sites in the anterior maxilla have a thin including clinical, cast model and radiographic exam-
buccal bone wall (Fig. 2), which probably contributes inations. After multiple tooth extractions and the use
to its loss following tooth extraction. of complete removable prostheses, the alveolar ridge
undergoes marked contraction in both vertical and
horizontal directions (13, 14, 32, 47, 48). Following
Histologic considerations several years of full denture use, individuals may
undergo a wide variation in alveolar ridge reduction
The inner portion of socket walls is named “alveolar and some may exhibit a fully resorbed alveolar ridge
bone proper” or bundle bone (a histological term) (16). Following single-tooth extraction, the ridge
and the remaining hard structure is called “alveolar exhibits a limited reduction in its vertical dimension,
bone”. The bundle bone is a lamellar bone, 0.2– but the horizontal reduction is substantial (Fig. 4; 62,
0.4 mm wide (65), composed of circumferential 63). It can be expected that: (i) up to 50% reduction of
lamellae, whilst the alveolar bone is also of the lamel- the original ridge width will occur; (ii) the amount of
lar type but composed of concentric and interstitial
lamellae and of marrow. In the bundle bone, the
Sharpey’s fibers are invested in such way that they
connect the periodontal ligament to the alveolar bone
and skeleton. Likewise, on the contralateral side of
the periodontal ligament, the dental cementum
invested with Sharpey’s fibers connects the periodon-
tal ligament to the dentin. As with root cementum
and the periodontal ligament, the bundle bone is a
tooth-dependent structure. Overall, the bundle bone
and the buccal bone plate frequently exhibit a similar

Fig. 3. Buccal–lingual section illustrating the most coronal

Fig. 2. Occlusal view of a dried skull specimen. Note the portion of the buccal bone wall. The buccal wall is made
limited thickness of the buccal bone wall at the central mainly by bundle bone. Polarized light. Toluidine blue
incisor regions. stain; original magnification 3 50.

123

provisional matrix. Subsequently, the provisional
matrix is penetrated by several vessels and bone-
forming cells, and finger-like projections of woven
bone are laid down around the blood vessels. Eventu-
ally, the projections completely surround a vessel and
the primary osteon is thus formed (Fig. 6). The pri-
mary osteons may be occasionally reinforced by
parallel-fibered bone. Woven bone can be identified
in the healing socket as early as 2 weeks after tooth
extraction and remains in the wound for several
weeks. Woven bone is a provisional type of bone
without any load-bearing capacity and therefore
needs to be replaced with mature bone types (lamel-
lar bone and bone marrow).
Bone modeling and remodeling phase
Bone modeling and remodeling is the third and last
phase of the socket-healing process. Bone modeling
is defined as a change in the shape and architecture
of the bone, whereas bone remodeling is defined as a
change without concomitant change in the shape and
architecture of the bone. The replacement of woven
bone with lamellar bone or bone marrow is bone
remodeling, whereas the bone resorption that takes
place on the socket walls leading to a dimensional
alteration of the alveolar ridge is the result of bone
modeling. Bone remodeling in humans may take sev-
eral months and exhibits substantial variability
Fig. 6. Micrograph illustrating primary osteons in the
healing socket. The collagen fibers have a woven organiza-
tion. Toluidine blue stain; original magnification 3 100.
Alveolar socket healing
among individuals (32, 74). In a recent study, Lindhe
et al. (54) examined the tissue composition of biop-
sies from 36 individuals retrieved from previous
socket sites in the posterior maxilla after >16 weeks of
healing. The authors reported that about 60–65% of
the tissue volume was made up of lamellar bone and
bone marrow. Thus, the complete remodeling of the
woven bone into lamellar bone and bone marrow
may take several months or years.
The resorption of the socket walls was studied in
biopsies obtained from human samples (32) and from
a series of studies in dogs (3–6, 10). A few weeks after
tooth removal, osteoclasts could be found around the
crest of both buccal and lingual walls and on the
outer and inner (bundle bone) portions of the socket
(Fig. 7). Bone modeling takes place equally on buccal
and lingual walls, but because the lingual bone is usu-
ally wider than the buccal bone wall, modeling results
in greater vertical bone loss at the thin buccal plate
than at the wide lingual wall. In addition, bone mod-
eling takes place earlier than bone remodeling, in
such way that about two-thirds of the modeling pro-
cess occurs in the first 3 months of healing (66). In
summary, modeling and remodeling processes during
socket healing result in qualitative and quantitative
changes at the edentulous site, which culminate in a
reduction of the dimension of the ridge.
Fig. 7. Buccal–lingual section of the socket wall a few
months following tooth extraction. Note the intense mod-
eling and remodeling process characterized by the pres-
ence of bone multicellular units and reversal lines.
Ladewig fibrin stain; original magnification 3 20.
125

provisional matrix. Subsequently, the provisional
matrix is penetrated by several vessels and bone-
forming cells, and finger-like projections of woven
bone are laid down around the blood vessels. Eventu-
ally, the projections completely surround a vessel and
the primary osteon is thus formed (Fig. 6). The pri-
mary osteons may be occasionally reinforced by
parallel-fibered bone. Woven bone can be identified
in the healing socket as early as 2 weeks after tooth
extraction and remains in the wound for several
weeks. Woven bone is a provisional type of bone
without any load-bearing capacity and therefore
needs to be replaced with mature bone types (lamel-
lar bone and bone marrow).
Bone modeling and remodeling phase
Bone modeling and remodeling is the third and last
phase of the socket-healing process. Bone modeling
is defined as a change in the shape and architecture
of the bone, whereas bone remodeling is defined as a
change without concomitant change in the shape and
architecture of the bone. The replacement of woven
bone with lamellar bone or bone marrow is bone
remodeling, whereas the bone resorption that takes
place on the socket walls leading to a dimensional
alteration of the alveolar ridge is the result of bone
modeling. Bone remodeling in humans may take sev-
eral months and exhibits substantial variability
Fig. 6. Micrograph illustrating primary osteons in the
healing socket. The collagen fibers have a woven organiza-
tion. Toluidine blue stain; original magnification 3 100.
Alveolar socket healing
among individuals (32, 74). In a recent study, Lindhe
et al. (54) examined the tissue composition of biop-
sies from 36 individuals retrieved from previous
socket sites in the posterior maxilla after >16 weeks of
healing. The authors reported that about 60–65% of
the tissue volume was made up of lamellar bone and
bone marrow. Thus, the complete remodeling of the
woven bone into lamellar bone and bone marrow
may take several months or years.
The resorption of the socket walls was studied in
biopsies obtained from human samples (32) and from
a series of studies in dogs (3–6, 10). A few weeks after
tooth removal, osteoclasts could be found around the
crest of both buccal and lingual walls and on the
outer and inner (bundle bone) portions of the socket
(Fig. 7). Bone modeling takes place equally on buccal
and lingual walls, but because the lingual bone is usu-
ally wider than the buccal bone wall, modeling results
in greater vertical bone loss at the thin buccal plate
than at the wide lingual wall. In addition, bone mod-
eling takes place earlier than bone remodeling, in
such way that about two-thirds of the modeling pro-
cess occurs in the first 3 months of healing (66). In
summary, modeling and remodeling processes during
socket healing result in qualitative and quantitative
changes at the edentulous site, which culminate in a
reduction of the dimension of the ridge.
Fig. 7. Buccal–lingual section of the socket wall a few
months following tooth extraction. Note the intense mod-
eling and remodeling process characterized by the pres-
ence of bone multicellular units and reversal lines.
Ladewig fibrin stain; original magnification 3 20.
125
  jo et al.
Arau
Stimulating factors
The initial healing responses in a wound are regulated
by signaling molecules (i.e. growth factors and cyto-
kines), such as platelet-derived growth factor, insulin-
like growth factors, transforming growth factor-beta
and fibroblastic growth factors. They initiate cell
migration, differentiation and proliferation as they
interact with each other in highly ordered temporal
and spatial sequences (53). These growth factors act
as mitogenic and angiogenic signals at the early stage
of bone healing. Once activated, growth factors insti-
gate a series of events via ligand–receptor interac-
tions, including signal transduction, gene
transcription, mRNA-directed protein biosynthesis
and secretion of post-translational proteins (44).
Few studies have examined the roles of growth fac-
tors and cytokines during socket healing (40, 74).
Fisher et al. (40) evaluated the expression of growth
factors during socket-healing events in a rabbit
model. The authors observed that: (i) fibroblast
growth factor-2 presented at higher levels at early
time points, before returning to lower levels; (ii) vas-
cular endothelial growth factor levels were main-
tained constant during healing; (iii) platelet-derived
growth factor-A levels increased during the first days
of socket healing; (iv) transforming growth factor-
beta1 presented a small elevation at early time points;
and (v) an increased expression of bone morphoge-
netic protein 2 was observed when osteoblast precur-
sors accumulated and began to proliferate. Trombelli
et al. (63) studied modeling and remodeling of
human extraction sockets and evaluated the expres-
sion of bone morphogenetic protein 7 during socket
healing. The results demonstrated that bone morpho-
genetic protein 7 increased during early and interme-
diate healing phases, and a period of increased bone
modeling and remodeling activity occurred, leading
to the deposition of woven bone from provisional
matrix. In summary, growth factors present multiple
activities, generally with overlapping actions, and a
simplistic characterization of their effects is not possi-
ble, or indeed appropriate.
What can we learn?
There are several lessons to be learned from the
various reports of local changes following tooth
extraction. The healed socket eventually fills with
newly formed bone and the alveolar ridge contracts.
The ridge reduction is larger in the molar region
126
(62), but it becomes more critical in the anterior
region as a result of esthetic demands. The anterior
maxillary region exhibits very thin socket walls (19,
46) that are frequently made up of only bundle
bone. As the bundle bone is a tooth-dependent
structure, it is gradually resorbed following exodon-
tia. Finally, the postextraction ridge reduction
appears to be related to several factors, including
surgical trauma, lack of a functional stimulus on the
bone walls, lack of bundle bone and periodontal lig-
ament and genetic information.
Tooth extraction is a traumatic procedure and, dur-
ing its course, the soft tissues are disrupted, the vas-
cular structures of the periodontal ligament are
damaged or destroyed and the principal fibers of the
periodontal ligament are severed (29). In addition, it
is well established in the dental literature that the ele-
vation of a full-thickness flap, in order to gain access
to the root, may cause resorption of thin bone walls
(50, 75–77; for reviews see 43, 70). However, different
animal and clinical studies have failed to support the
concept that tooth extraction without flap elevation
prevents ridge reduction (8, 17, 33, 39). These studies
indicate that the surgical trauma promoted by the
removal of the tooth itself overlaps with the surgical
trauma promoted by the elevation of a full-thickness
flap.
The surgical trauma caused by tooth extraction
may be limited by minimally invasive surgical proce-
dures (58). Such procedures aim to prevent expansion
of the socket housing, which otherwise may fracture
the thin adjacent bony walls. For this purpose, the
use of forceps to luxate the tooth by applying forces
toward the buccal palatal/lingual aspects of the
socket is not recommended. Likewise, the forceps
should not perform rotational movements, as the
cross-section shape of a root is seldom circular. Sev-
eral new surgical instruments, which promote mini-
mally invasive tooth extraction, are currently
commercially available. Periotomes and vertical
tooth-extraction systems are among the instruments
most frequently used for this purpose. Periotomes are
instruments designed to sever the periodontal liga-
ment fibers at the mesial and distal aspects of the
socket, in order to facilitate and improve the effi-
ciency of root elevators. Vertical tooth-extraction sys-
tems are, on the other hand, designed to pull roots in
a vertical direction and hence avoid any damage to
the socket walls. In both techniques described above,
no pressure is applied to the buccal socket wall; how-
ever, such techniques are efficient only for conical or
straight roots.
 Table 1. Clinical studies that evaluated grafting sockets with different materials and mechanical barriers to prevent alveolar ridge reduction following tooth extraction

Authors n Material Method of Follow-up Outcome

evaluation

Camargo et al. 16 patients32 Bioactive glass (test) vs. extraction Clinical 6 months Change in ridge width (test: 3.48  2.68 mm;
(24) sockets alone (control) control: 3.06  2.41 mm)
Change in ridge height (test: 0.38  3.18 mm;
control: 1.00  2.25 mm)
No difference between groups
Iasella et al. (45) 24 patients24 Tetracycline hydrated FDBA (test) vs. Clinical and 4–6 months Change in ridge width (test: from 9.2  1.2 mm to
sockets extraction alone (control) histologic 8.0  1.4 mm; control: from 9.1  1.0 mm to
6.4  2.2 mm)
Change in ridge height (test: 1.3  2.0 mm; control:
0.9  1.6 mm)
FDBA improved ridge height and width dimensions
compared with extraction alone
Serino et al. (67) 36 patients Polylactide and polyglycolide sponge Clinical and 6 months Change in ridge height (test: 0.2  1.5 mm; control:
39 sockets (test) vs. extraction alone (control) histologic 0.7  1.2 mm)
Test group may preserve or reduce alveolar bone
resorption
Luczyszyn et al. 15 patients Acellular dermal matrix and resorbable Clinical and 6 months Ridge width (test: 6.8  1.26 mm; control:
(55) 30 sockets hydroxyapatite (test) vs. acellular histologic 5.53 + 1.06 mm)
dermal matrix alone (control) Acellular dermal matrix was able to preserve ridge
thickness and the additional use of resorbable
hydroxyapatite favored preservation of the ridges
Barone et al. (15) 40 patients Corticocancellous porcine bone (test) Clinical and 7 months Change in ridge width (test: 2.5  1.2 mm; control:
40 sockets vs. extraction alone (control) histologic 4.3  0.8 mm)
Change in ridge height (test: 0.7  1.4 mm; control:
3.6  1.5 mm)
Test group limited resorption
Cardaropoli & 10 patients Bovine bone mineral (case series) Clinical and 4 months Change in ridge width: from 11.8  1.53 mm to
Cardaropoli (30) 10 sockets histologic 9.95  2.31 mm

Neiva et al. (61) 24 patients Putty-form hydroxyapatite matrix Clinical, histologic 16 weeks Change in ridge width (test: 1.31  0.96 mm; control:
24 sockets combined with the synthetic cell- and radiographic 1.43  1.05 mm)
binding peptide P-15 (test) vs. Change in ridge height (test: 0.15  1.76 mm; control:
extraction alone (control) 0.56  1.04 mm)
A favorable response was observed when putty P15 was
applied to extraction sockets

127
Alveolar socket healing
 Table 1. (Continued)
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128
Authors n Material Method of Follow-up Outcome
evaluation
 jo et al.

Mardas et al. (56) 26 patients B-TCP (test) vs. bovine bone mineral Clinical and 8 months Change in ridge width (test: 1.1  1.0 mm; control:
26 sockets (control) histologic 2.1  1.0 mm)
Change in ridge height (test: 0.4  0.5 mm; control:
0.1  0.7 mm)
No difference between groups
Fernandes et al. 18 patients Acellular dermal matrix and anorganic Clinical 6 months Change in ridge width (test: 2.53  1.81 mm; control:
(38) bone matrix cell-binding peptide P-15 3.40  1.39 mm)
(test) vs. acellular dermal matrix alone Change in buccal crest height (test: 1.20  2.02 mm;
control: 1.50  1.15 mm)
No difference between groups
Nam et al. (59) 42 patients Synthetic oligopeptide-coated bone Clinical and 6 months Change in ridge width (test: 1.2  1.5 mm; control:
44 sockets mineral (test) vs. bone graft without histologic 1.3  1.4 mm)
peptide (control) Change in buccal crest height (test: 2.3  3.6 mm;
control: 2.3  2.1 mm)
No difference between groups
Brkovic et al. (20) 20 patients B-TCP/type I collagen cones with (test) Clinical and 9 months Change in ridge width (test: from 7.39  2.00 mm to
20 sockets or without (control) a barrier histologic 6.53  1.83 mm; control: from 7.88  2.33 mm to
membrane 6.59  2.44 mm)
Change in ridge height (test: from 3.00  1.85 mm to
3.38  1.94 mm; control: from 3.00  1.25 mm to
3.22  1.48 mm)
No difference between groups
Mardas et al. (57) 27 patients B-TCP (test) vs. bovine bone mineral Radiographic 32 weeks Changes in ridge hight (test group:
27 sockets (control) M side 0.9  1.2 mm; D side 0.7  1.8 mm;
control group: M side 0.4  1.3 mm; D side
0.7  1.3 mm)
No difference between groups
Kim et al. (51) 20 patients Collagen sponge and xenogeneic bone Histologic 3 months Resorption in ridge width (test: 14.26%; control:
20 sockets grafts (test) vs. extraction alone 20.74%)
(control) Xenograft prevents the horizontal resorption of the
alveolar ridge, and the upper collagen sponge blocks
the infiltration of soft tissues to the lower area
Kutkut et al. (52) 16 patients Calcium sulfate hemihydrate and Clinical and 3 months Change in ridge width (test: 1.7  1.4 mm;
16 sockets platelet-rich plasma (test) vs. collagen histologic control: 1.7  1.6 mm)
resorbable plug (control) Change in ridge height (test: 0.2  0.9 mm; control:
1.0  0.8 mm)
No difference between groups
 Table 1. (Continued)

Authors n Material Method of Follow-up Outcome

evaluation

Brownfield & 17 patients Osteoinductive demineralized bone Clinical, histologic, 10–12 weeks Change in ridge width (test: 1.00  0.40 mm;
Weltma (21) 20 sockets matrix with cancellous bone chips radiographic and control: 1.30  1.00 mm)
(test) vs. extraction alone (control) tomographic Change in ridge height (test: 0.80  1.20 mm;
control: 1.20  0.40 mm)
No difference between groups
Gholami et al. 12 patients Synthetic nanocrystalline Clinical and 6–8 months The width in test group 2 decreased from
(41) 28 sockets hydroxyapatite (test group 1) X bovine histologic 7.75  1.55 mm to 6.68  1.85 mm and in test group
bone mineral (test group 2) 1 decreased from 7.36  1.94 mm to 6.43  2.08 mm
No difference between groups
Toloue et al. (72) 21 patients Calcium sulfate (test) vs. FDBA Clinical and 3 months Change in ridge width (test: 1.33  1.22 mm;
31 sockets (control) histologic control: 1.03  0.87 mm)
Change in ridge height (test: 0.32  1.69 mm;
control: 0.05  1.46 mm)
No difference between groups
Cardaropoli et al. 41 patients Bovine bone mineral (test) vs. Clinical and 4 months The test group showed less reduction in ridge width
(31) 48 sockets extraction alone (control) histologic (1.04  1.08 mm vs. 4.48  0.65 mm) and height
(0.46  0.46 mm vs. 1.54  0.33 mm)
Bovine bone mineral considerably limits the amount of
horizontal and vertical bone resorption
Cook & Mealey 44 patients Bovine xenograft (test group 1) vs. Clinical and 21 weeks Change in buccal ridge height (test group 1:
(35) 44 sockets sponge composed of 70% type I histologic 0.14  2.21 mm; test group 2: 0.03  2.81 mm)
bovine collagen coated with 30% Change in lingual ridge height (test group 1:
nonsintered hydroxyapatite (test 0.21  3.04 mm; test group 2: 1.18  1.93 mm)
group 2) Change in ridge width (test group 1: 1.57  1.21 mm/
test group 2: 1.16  1.44 mm)
No significant difference between groups
Clozza et al. (34) 13 patients Bioactive glass (case series) Tomographic 3 months Preservation of about 77% of the original width
32 teeth dimensions
The bone loss in width was 1.8  1.1 mm; vertical
bone loss was 2.7  1.1 mm

129
Alveolar socket healing

130
Table 1. (Continued)
Authors n Material
Jung et al. (49) 40 patients Beta-tricalcium phosphate particles Tomographic
40 sockets (test group 1) vs. bovine bone mineral
covered with a collagen matrix (test
group 2) vs. DBBM-C covered with an
autogenous soft-tissue graft (test
group 3) vs. spontaneous healing
(control)
Shakibaie-M (68) 10 patients Bovine bone material (test group 1) vs. Clinical and
32 sockets or hydroxyapatite and silicon dioxide histologic
(test group 2) vs. stypro gelatin sponge
(control)
Thalmair et al. 30 patients Prehydrated collagenated cortico- Clinical
(71) 30 sockets cancellous porcine bone and free
gingival graft (test group 1) vs. free
gingival graft alone (test group 2) vs.
xenogenic bone substitute (test group
3) vs. extraction alone (control)
Arau

jo et al. (12) 28 patients Bovine bone mineral (test) vs.
28 sockets extraction alone (control)
FDBA, freeze-dried bone allograft; B-TCP, beta- tricalcium phosphate; M side, mesial side; D side, distal side; DBBM-C, bovine bone mineral; CM, collagen matrix.
Arau
 jo et al.
Method of Follow-up Outcome
evaluation
6 months Vertical changes ranged between 0.6 mm ( 10.2%)
for control and a gain of 0.3 mm (5.6%) for test group
3 on the lingual side, and between 2.0 mm ( 20.9%)
for beta-tricalcium phosphate and a gain of 1.2 mm
(8.1%) for test group 3 on the buccal side
The most accentuated ridge width changes were
recorded 1 mm below the crest: 3.3 mm ( 43.3%,
control), 6.1 mm ( 77.5%, beta-tricalcium
phosphate), 1.2 mm ( 17.4%, test group 2) and
1.4 mm ( 18.1%, test group 3)
DBBM-C covered with CM or autogenous soft-tissue
graft, resulted in reduced vertical and horizontal
changes
12–14 weeks Alveolar ridge width reduction (test group 1 = 0.5 mm;
test group 2 = 1.5 mm; control = 2.0 mm)
Alveolar ridge height reduction (test group 1 = 1.0 mm;
test group 2 = 1.5 mm; control = 2.0 mm)
Fixed gingiva width reduction (test group 1 = 0.5 mm;
test group 2 = 2.4 mm; control = 2.5 mm)
Bovine xenograft resulted in better bone quality and
quantity
4 months All groups displayed contour shrinkage at the
buccal aspect ranging from a mean horizontal
reduction of 0.8  0.5 mm (test group 1) to
2.3  1.1 mm (control)
Free gingival graft limited the contour shrinkage
Tomographic 4 months Bovine bone mineral counteracted the reduction in
hard tissue
Reduction in hard tissue was 3% in the test group
compared with 25% in the control.

Teeth provide support for very thin bone walls,
although fenestrations and dehiscence may occur
naturally when the bone thickness is below a certain
threshold (65). It is suggested, however, that implants
should be provided with bone walls about 1- to 2-
mm-wide on buccal and lingual aspects to allow a
stable bone height to be maintained (22, 42). The rea-
sons why teeth can support thin bone walls, and why
implants seem to fail to do so, remains obscure. It has
been suggested, however, that the presence of bundle
bone and periodontal ligament around teeth are
likely explanations. Bundle bone is capable of existing
in thinner dimensions than are alveolar or basal
bones because the periodontal ligament provides the
functional stimulus as well as the nutritional and cel-
lular source for its maintenance.
It is now well established that following tooth
extraction the ridge crest moves toward the long axis
of the basal bone (16, 63). The shape of the jawbone
appears to return to the shape that was present prior
to the development of the alveolar process during
tooth eruption. The lack of a functional stimulus on
the bone walls and the need for tissue adjustment to
meet “genetically” determined demands regarding
ridge geometry in the absence of teeth (2) may
explain this modification.
Grafting sockets with different materials, and the
use of mechanical barriers, have been proposed to
prevent alveolar ridge reduction, secondary to bone
modeling. Clinical studies have been performed to
evaluate the outcome of such surgical protocols
(Table 1). The results from these studies indicate
that ridge contraction following tooth extraction
can be diminished when combined with socket
grafts and/or the use of mechanical barriers. Exper-
imental studies in a dog model (6, 9) have demon-
strated that placement of bone substitutes in the
fresh extraction socket failed to inhibit the pro-
cesses of modeling and remodeling that took place
in the socket walls following tooth extraction. The
authors observed, however, that the graft supported
de novo hard-tissue formation, in particular in the
cortical region of the extraction site, and the
dimension and profile of the alveolar ridge was bet-
ter preserved. The authors concluded that the
placement of a biomaterial in an extraction socket
may modify modeling and compensate for the buc-
cal bone loss. The histological observations
described above were confirmed by a recent ran-
domized clinical trial (12) that evaluated radio-
graphically the dimensional alterations of the
alveolar ridge at socket sites grafted with anorganic
bovine bone. The authors observed that after
Alveolar socket healing
4 months of healing, the buccal bone wall at the
grafted socket sites was markedly reduced in
height. On the other hand, the cross-sectional area
of the grafted sites exhibited a reduction of only
3% of their initial dimensions, whilst in the non-
grafted sites, the corresponding reduction was 25%.
It has been well established in the literature that
immediate implant placement in fresh extraction
sockets fails to prevent bone modeling and thus
maintains the original shape of the ridge (3–5, 18, 33,
36, 73). The use of hard- or soft-tissue grafts with
immediate implant placement to prevent ridge
reduction has been evaluated in various clinical and
experimental studies (11, 25–28, 37, 64, 78). In these
studies, the hard-tissue graft, mainly a bone substi-
tute, was placed in the space between the implant
surface and the inner surface of the buccal bone wall,
whilst the soft-tissue graft was adapted to the outer
surface of the bone wall. The findings from these
reports demonstrate that graft procedures, combined
with implant placement, may counteract ridge altera-
tions following tooth extraction.
In summary, there are four fundamental learnings
from current knowledge of the socket-healing pro-
cess. First, a relatively thin buccal bone wall at the
anterior maxillary region characterizes the alveolar
socket. Such a thin bony wall provides the framework
for the outline of the buccal aspect of the alveolar
process. Second, the buccal bone wall will eventually
be resorbed following tooth extraction. Following
buccal bone resorption, the soft tissue collapses into
the socket, creating a ridge defect. Third, the immedi-
ate placement of an implant does not prevent buccal
bone loss, nor, indeed, does a socket graft with vari-
ous biomaterials. In contrast, grafting sockets limits
the collapse of the soft tissues into the healing alveo-
lar socket and, at the same time, supports bone for-
mation. Thus, the preservation of the ridge
dimension occurs as a compensatory mechanism for
the buccal bone loss. Finally, tooth extraction, once
considered a simple and straightforward surgical pro-
cedure, should be performed with the understanding
that ridge reduction will follow and thus further clini-
cal steps should be considered to compensate for
such a change when considering future reconstruc-
tion or replacement of the extracted tooth.
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