CLINICAL

Flapless Alveolar Ridge Preservation Utilizing the

‘ Socket-Plug’’ Technique: Clinical Technique and
Review of the Literature
Georgios Kotsakis, DDS1*
Vanessa Chrepa, DDS2
Nicolas Marcou, DDS3
Hari Prasad, BS, MD.t, MS4
James Hinrichs, DDS, MS5

It has been documented that after every extraction of one or more teeth, the alveolar bone of the respective
region undergoes resorption and atrophy. Therefore, ridge preservation techniques are often employed after
tooth extraction to limit this phenomenon. The benefits of a flapless procedure include maintenance of the
buccal keratinized gingiva, prevention of alterations to the gingival contours, and migration of the mucogingival
junction that are often experienced after raising a flap. The purpose of this article is to review the literature
concerning flapless ridge preservation techniques with the aid of collagen plugs for occlusion of the socket. The
term ‘‘socket-plug’’ technique is introduced to describe these techniques. The basic steps of the ‘‘socket-plug’’
technique consist of atraumatic tooth extraction, placement of the appropriate biomaterials in the extraction
site, preservation of soft tissue architecture employing a flapless technique, and placement and stabilization of
the collagen plug. A case example is presented that illustrates the steps used in this technique.

Key Words: ridge preservation, tooth extraction, dental implants, collagen plug

INTRODUCTION alveolar bone resorption process occurs within the

first 3 to 6 months post extraction, but this

I
t is well documented in the literature that
procedure is chronic, and the alveolar bone
following every tooth extraction, resorption of
continues to resorb even 25 years after the
the alveolar bone is triggered in the respective
extractions.6 Resorption rate varies among individ-
region.1,2 Alveolar ridge resorption is a chron-
uals and may even fluctuate for the same individual
ic, irreversible phenomenon, which is estimat- within different periods of time. Additionally, there
ed to lead to a reduction in width ranging between is a marked difference on the resorption patterns
2.6 and 4.6 mm and in height between 0.4 and 3.9 between the maxillary and the mandibular bone,
mm post extraction.3–5 The vast percentage of the with sockets in the mandible being resorbed up to 4
times faster than those in the maxilla.4,6 If no actions
1
Advanced Education Program in Periodontology, University of are employed for the prevention of this phenom-
Minnesota, Minneapolis, Minn.
2
Advanced Education Program in Endodontics, University of
enon, 40%–60% of the total alveolar bone volume is
Texas Health Science Center, San Antonio, Tex. lost during the first 2–3 years post extraction, and
3
University of Athens, Athens, Greece this phenomenon continues incessantly with a rate
4
Hard Tissue Research Laboratory, University of Minnesota,
Minneapolis, Minn. of 0.25%–0.5% loss per year7 (Figure 1).
5
Advanced Education Program in Periodontology, University of The aim of this paper is to review the data from
Minnesota, Minneapolis, Minn.
* Corresponding author, e-mail: kotsa001@umn.edu the literature that involves flapless ridge preserva-
DOI: 10.1563/AAID-JOI-D-12-00028 tion procedures employing the use of collagen

690 Vol. XL /No. Six /2014

 Kotsakis et al

FIGURES 1–5. FIGURE 1. Clinical view of an extraction site that was not treated with a ridge preservation technique (black
arrows pointing at the residual ridge). FIGURE 2. Pre-extraction decision tree. FIGURE 3. A serrated periotome is utilized to
severe the periodontal ligament, thus aiding in the atraumatic extraction. FIGURE 4. The graft is placed up to the level of the
bone crest. FIGURE 5. The collagen plug is used to protect the graft. When the collagen plug is moistened with saline or
blood, it becomes malleable so it can easily adapt in the coronal part of the socket.

plugs and report their efficacy in preserving alveolar
ridge dimensions. The authors have introduced the
term ‘‘socket-plug’’ technique to include all varia-
tions of this commonly used technique, which are
used by many clinicians in everyday practice.
Review of the literature
The first attempts to study the alveolar ridge
resorption phenomenon started in the early
1960s,8 whereby the submerged root concept was
introduced as a ridge preservation technique.9,10
Contemporary socket preservation techniques in-
volve the placement of different biomaterials in the
socket.5,11 The choice of biomaterials that will be
used is correlated to the purpose for which the
technique is going to be used (Figure 2).
Bartee12 proposed 3 categories of ridge preser-
vation based on the resorbability pattern of the
graft material that was employed.
(1) Long-term ridge preservation: In this case the
technique is used either for pontic site devel-
opment or to improve the stability of removable
appliances. Nonresorbable materials are used
for this indication, and as a result, the placement
of implants in these sites is not favored.
(2) Medium-term or transitional ridge preservation:
Slowly resorbable bone graft materials are used
in ridge preservation allowing for the preserva-
tion of the alveolar ridge for a protracted period
of time while enabling the placement of an
osseointegrated implant in the site after an
initial healing period, even in the presence of
some unresorbed graft particles. Transitional
ridge preservation is indicated in cases where it
is still undetermined whether the patient is
going to restore the edentulism with an
implant, or in cases where the patient has
chosen to have an implant placed but will be
unable to return and place the implant for a
substantial amount of time.
(3) Short-term ridge preservation: The objective of
this technique is to maintain the postextraction
alveolar dimensions during the initial healing
phase in order to allow for the placement of an
implant in the shortest possible timeframe.
As far as the coverage of the graft is concerned,
primary soft tissue coverage with or without a
membrane, sealing of the socket with a free

Journal of Oral Implantology 691

Flapless Alveolar Ridge Preservation With ‘‘Socket-Plug’’ Technique
gingival graft or a connective tissue graft, and
placement of a collagen plug for socket occlusion
have all been proposed.13–16 Barrier membranes
have been employed showing good results in ridge
preservation in a manner similar to guided bone
regeneration.17–19 The main drawback associated
with this technique is that it requires primary soft
tissue closure. Flap advancement for primary
closure causes repositioning of the mucogingival
junction, displacement of the keratinized mucosa
towards the crestal region, and increased postop-
erative swelling and discomfort.20 Furthermore, if
the membrane undergoes secondary exposure,
there is a risk for infection of the graft, thus
jeopardizing the outcome of the preservation
procedure.21 The ‘‘socket seal surgery’’ technique
is a ridge preservation procedure that does not
require flap advancement and was introduced to
counter these technique-inherent drawbacks.22 This
minimally invasive ridge preservation procedure
involves bone and soft tissue grafting. The extrac-
tion socket is filled with the bone graft of choice,
and then a soft tissue graft of adequate size is
harvested from the palate and is placed over the
graft in order to seal the socket.23 Even though the
‘‘socket seal surgery’’ technique was novel in
introducing a ridge preservation procedure that
would not require primary flap closure, it still did
not minimize the postoperative discomfort due to
the soft tissue graft harvesting.
The ‘‘BioCol’’ technique was introduced shortly
afterwards using the same principles as the ‘‘socket
seal surgery,’’ but specifically used anorganic bovine
bone mineral as a bone substitute and replaced the
soft tissue graft with a collagen plug that was
stabilized with a horizontal mattress suture to
occlude the socket. Cyanoacrylate was placed over
the collagen to harden the material and decrease
permeability of this barrier.24 This new concept
reduced postoperative discomfort to a minimum, as
there was no need for flap elevation or graft
harvesting. After the introduction of this technique,
many modifications were proposed in the literature,
differing either in the graft that was used (‘‘allo-
plug’’ technique, ‘‘Nu-mem’’ technique) or in the
placement of the collagen plug (‘‘modified BioCol’’
technique).25–27
The modified Bio-Col technique suggested an
alternative approach to the handling and stabiliza-
tion of the collagen plug. Only the terminal one fifth
692 Vol. XL /No. Six /2014
of the collagen plug is utilized to cover the graft,
rather than layering the bulk of it to the level of the
free gingival margin. The horizontal mattress suture
was eliminated, and a fixed or removable interim
prosthesis with an ovate pontic was fabricated to
cover the collagen plug to aid in retention and
formation of an esthetic soft tissue profile at the
site.26 Recently, the ‘‘allo-plug’’ technique was
introduced, where the authors substituted the use
of bovine xenograft with a human mineralized bone
allograft.27 The rationale behind shifting from one
bone graft to the other was the large number of
remaining bovine xenograft particles observed even
after a significant healing period of time.19,27
According to the previous authors’ views, freeze-
dried bone allograft (FDBA) may provide a better
potential for osteoconductivity than anorganic
bovine xenograft. In this technique, a cross-mattress
suture was placed over the collagen plug for
stabilization rather than placing cyanoacrylate or
other tissue adhesive. The term ‘‘socket-plug’’
technique is coined by the authors in this paper
to encompass all variations of this socket preserva-
tion technique.
‘‘Socket-plug’’ technique
The ‘‘socket-plug’’ technique consists of 4 distinct
steps.11,28
(1) Atraumatic extractions after careful surgical
preparation of the soft and hard tissues using
periotomes as illustrated in Figure 3: Several authors
propose that a sulcular incision is done with the aid
of a number 15 or 15c scalpel in order to dissect the
crestal fibers.11 Careful curettage and debridement
of the socket is performed. If residual inflammatory
tissue is left in the socket, the bone graft may be
resorbed because of the low pH environment, and
the bone regeneration process may be compro-
mised.29 It is important that clinicians do not apply
bicortical pressure on the alveolar ridge after the
extraction of the tooth.30
(2) Placement of the appropriate biomaterial:
Autogenous grafts are said to be the ‘‘gold
standard’’ in bone grafting because of their
osteogenetic characteristics and biocompatibility.31
Common intraoral donor sites are the external
oblique line, mental protuberance, and maxillary
tuberosity. As far as ridge preservation is concerned,
the autologous graft has not been found to display
any osteoinductive or osteogenetic effects.32,33 It is

rapidly resorbed and replaced by vital bone without
diminishing the resorptive procedure.33 A major
disadvantage of autologous bone grafting is patient
discomfort, and any advantage associated with the
use of this type of graft should always be weighed
against this disadvantage.
Allografts have also been employed in ridge
preservation procedures, contributing positively in
the dimensional stability of the postextraction
socket. Allografts are slowly absorbed in socket
preservation applications. Allografts that contain
calcium and phosphorous salts (FDBA) are resorbed
more slowly than those that have been demineral-
ized.34 For the first 3–6 months after the placement
of the graft in the socket, particles of the graft are
still found in the socket surrounded by connective
tissue and newly formed bone.35
Xenografts are employed by many clinicians for
ridge preservation. An animal study36 reported that
3 months after the use of Bio-Oss in surgically
created jaw defects that resembled postextraction
resorption defects, residual graft particles remained
occupying approximately 30% of the defect post-
healing. Moreover, no osseointegration was
achieved for implants placed in the regenerated
defects 3 months after the placement of the
xenograft. In another paper by Artzi et al,37 15
sockets were filled with inorganic bovine graft. Nine
months following the graft placement, satisfactory
ridge dimensions were observed, but histologic
study revealed graft particles in connection with the
newly formed bone at a constant 30% across the
socket. Interestingly, the histomorphometric mea-
surements revealed that the coronal part of the
socket consisted predominantly of loose connective
tissue (52.4%), followed by woven bone (15.9%) and
remaining graft particles (30%). Descending from
the coronal to the apical third of the socket, there
was a marked shift of the proportion of connective
tissue to the newly formed bone, with the bone
being better trabeculized and occupying 63.9% of
the socket volume, while connective tissue was
decreased to 9.5%.37Throughout the whole socket
dimension, the percentage of nonabsorbed graft
remained constant at about 30%. The use of
osseointegrated implants was predictable at 9
months after socket grafting. On the other hand,
it has been documented that even though the
graft’s particles remain at the implantation site for a
protracted period of time, they are surrounded by
Kotsakis et al
vital, newly formed bone.38 In an animal study,39
vital host bone was found to separate the
remaining xenograft particles from the implant
surface, and it was suggested that the remaining
particles may have no negative effect on the
osseointegration of implants. It can be concluded
that xenografts can be used for transitional ridge
preservation because of their slow resorption rate,
with remaining particles being found in the socket
even after 4 years.40
Alloplastic materials are a large and diverse
group of bone substitutes that include hydroxyap-
atite, calcium phosphate, bioactive glass, and
calcium sulfate. Each category of alloplastic mate-
rials has a different resorption pattern ranging from
the rapidly resorbing calcium sulfate that is used for
short-term ridge preservation41 to condensed hy-
droxyapatite that is practically nonresorbable and is
suitable for long-term ridge preservation.42 Recent-
ly, there is an interest in the clinical application of
new alloplastic graft materials that have unique
distribution characteristics in comparison to the
traditional bone substitutes that come in the form
of particles.43 One such material will be discussed in
the case example below (Figure 4).
(3) Flapless design: Many authors have suggest-
ed various flap designs in order to establish primary
closure of the socket. There is not adequate
research data to clearly demonstrate that flapless
socket preservation techniques are superior to
techniques that involve raising a flap, but an animal
study reported that the detachment of the perios-
teum from the buccal site of the ridge leads to an
increase of the resorption rate, resulting in an
increase of the ridge resorption of approximately
0.7 mm. 44 Consequently, there seems to be
evidence to promote the idea that the use of
socket preservation techniques that do not require
the opening of a flap may be superior to putting
effort in achieving primary closure of the socket,
wherever they are indicated. Moreover, it has been
shown in the literature that where a connective
tissue graft, a collagen sponge, or a collagen
membrane was left to heal without primary closure,
excellent preservation of the vertical dimension of
the ridge was achieved or even an increase in
height was noted, which could be attributed to an
increase in the soft tissue volume.28,45,46 The use of
a collagen sponge has particularly been found to
not only protect the bone substitute but to present
Journal of Oral Implantology 693
Flapless Alveolar Ridge Preservation With ‘‘Socket-Plug’’ Technique
hemostatic properties as well as to minimize
discomfort during the postsurgical period. In
addition to stabilizing the blood clot, collagen
plugs act as chemotactic agents for fibroblasts.47
(4) Suturing: The collagen plug has a dual
purpose. It is placed to prevent the wash out of
the bone graft and to induce blood clot formation
and stabilization of the clot by stimulation of the
platelet aggregation.27,47 For the collagen plug to be
stabilized over the socket, suturing is done without
tension in order to secure the plug without distorting
the gingival architecture. Preferably, a single hori-
zontal mattress suture is executed (Figure 5).
CASE PRESENTATION
A 30-year-old nonsmoking male patient presented
with a nonrestorable maxillary left second premolar
due to extensive decay (Figure 6). Extraction and
ridge preservation were scheduled. The patient was
in good general health and had no contraindica-
tions regarding this treatment plan. After informed
consent was obtained from the patient, he was
instructed to rinse with a chlorhexidine 0.12%
solution for 1 minute (Chlorhexil, Intermed, Athens,
Greece). Following administration of local anesthe-
sia, the width of the alveolar bone was measured at
5 and 7 mm below the line connecting the
cementoenamel junction (CEJ) of the 2 neighboring
teeth with the aid of a bone caliper. The measure-
ment was 9.3 mm and 8.9 mm, respectively.
Subsequently, extraction of the involved tooth
was performed as atraumatically as possible (Fig-
ures 7 and 8). Care was given not to raise a flap in
order to maintain the vascularization of the socket
walls. After thorough debridement of the socket, a
calcium phosphosilicate (CPS) putty graft was
injected into the socket (NovaBone Dental Putty,
NovaBone Products LLC, Alachua, Fla) (Figure 9).
The graft was placed up to the crest of the bone
and a collagen plug (CollaPlug, Zimmer Dental,
Carlsbad, Calif) was trimmed and adapted over the
graft in order to occlude the socket (Figure 10). The
plug was stabilized with a single mattress suture.
Effort was made to avoid applying any pressure
with the suture to preserve the gingival architec-
ture. The healing process was uneventful and the
patient was recalled at 6-month intervals for
prophylaxis and evaluation of the healed site.
694 Vol. XL /No. Six /2014
Implant placement was to be scheduled when the
patient could financially afford the treatment.
At the 6-month appointment, the bone width
measurement was repeated and revealed a reduc-
tion of 1.1 mm at 5 mm below the reference point
and 1.0 mm at the 7-mm point.
Eighteen months post extraction, the measure-
ment of the bone width at 5 and 7 mm below the
line connecting the CEJ of the 2 neighboring teeth
revealed minimal ridge resorption with measure-
ments of 8.1 and 7.7 mm, respectively (Figures 11
and 12).
It appears that the major percentage of the
resorption of the ridge occurred within the first 6
months following the extraction, which is in
agreement with previously published data.7,17 The
measurements were taken at 5 and 7 mm from the
reference point because a smaller distance may
have involved the sulcus of the tooth instead of the
alveolar bone. Simon et al48 performed similar
measurements using a ridge mapper to determine
the width at 3 and 5 mm apical to the alveolar crest.
In another study,49 bone width was estimated 4 mm
apical to the CEJ of the neighboring teeth as
measured in cone-beam computerized tomogra-
phy. The authors chose to measure at least 5 mm
below the line connecting the CEJ of the 2
neighboring teeth because of the possibility that
in cases with a slight resorption of the buccal plate,
a 3-mm measurement may stop on the cementum
of the root instead of the buccal plate. Therefore, 2
measurements at 5 and 7 mm were taken in order
to minimize measurement error and verify the
validity of the measurements. Additionally, the
exact distance between the site of measurement
and the root surface of the nearest tooth was
recorded to ensure that the follow-up measurement
would be standardized and reproducible.50
At the 18-month recall appointment, the patient
was able to proceed financially with implant
placement, thus we were able to harvest a 3.0 3
6.0 core and preserve it in (10%) neutral buffered
formalin. Upon receipt in the Hard Tissue Research
Laboratory, the core was sectioned in half through
the area of interest and immediately dehydrated
with a graded series of alcohols for 9 days.
Following dehydration, the specimen was infiltrated
with a light-curing embedding resin (Technovit
7200 VLC, Kulzer, Wehrheim, Germany). Following
20 days of infiltration with constant shaking at
 Kotsakis et al

FIGURES 6–13. FIGURE 6. Preoperative view of the nonrestorable upper left second premolar. FIGURE 7. The involved tooth was
extracted without flap reflection. FIGURE 8. Immediate postextraction radiographic view of the socket. FIGURE 9. The socket
was filled with an alloplastic graft that displays putty consistency and is easily injected into the socket, thus saving
important clinical time. FIGURE 10. A collagen plug is trimmed and adapted over the graft in order to occlude the socket.
FIGURE 11. Clinical view of the healed site 18 months post extraction. The dimensional stability of the ridge will allow for the
ideal restoratively driven positioning of an implant. FIGURE 12. Radiographic image of the socket at the 18-month recall
appointment. The trabecularization of the regenerated bone is similar to the native bone. Note the pneumatization of the
sinus. FIGURE 13. Calcium phosphosilicate putty core at 6 months. The red-stained tissue is mineralized, newly regenerated
bone with visible cell nuclei. Some residual graft particles can be seen in all images. New bone formation is quite robust
surrounding particles of bio-active glass. The yellowish-green staining shows osteoid and the newly entrapped osteocytes in
the very immature bone. NB indicates new bone; CPS, calcium phosphosilicate putty; OS, osteoid; and OB, osteoblast.

normal atmospheric pressure, the specimen was
embedded and polymerized by 450 nm light with
its temperature never exceeding 408C. The speci-
men was then prepared by the cutting/grinding
method of Donath and Breuner.51,52 The specimen
was cut to a thickness of 150 lm on an EXAKT
cutting/grinding system (EXAKT Technologies, Okla-
homa City, Okla). Following this, the core was
polished to a thickness of 45–60 lm using a series
of polishing sandpaper discs from 800 to 2400 grit
using an EXAKT microgrinding system followed by a
final polish with 0.3-micron alumina polishing paste.
The slides were stained with Stevenel’s blue and
Van Gieson’s picrofuchsin and were evaluated.
Histologic analysis of the core showed trabeculae
of varying thicknesses and good connectivity. New
bone that had formed around particles of CPS putty
had formed bridges with other areas of new bone,
resulting in a good cancellous bone pattern (Figure
13).

Journal of Oral Implantology 695

Flapless Alveolar Ridge Preservation With ‘‘Socket-Plug’’ Technique
DISCUSSION
It is frequently necessary for clinicians to extract
teeth for a variety of reasons such as root fracture,
periapical pathology, extensive decay, or periodon-
tal disease. Even when removal of the tooth is
exercised in the most atraumatic way, vertical and
horizontal bone resorption is an inevitable natural
consequence. Approximately 40% of bone height
and 60% of bone width are lost in the first 6 to 12
months post extraction.7,17 Variations of the ‘‘sock-
et-plug’’ technique have been used for more than a
decade to help minimize the amount of bone loss
and ensure the esthetics of the future restoration.24
The major limitation for the application of this
technique is the status of the buccal plate. When
the buccal plate is severely damaged, a barrier
membrane should be employed in order to contain
the graft and prevent the soft tissue from occupy-
ing the buccal space.53 Another contraindication for
the ‘‘socket-plug’’ technique is acute infection of the
tissues surrounding the hopeless tooth. Acute
infection of the area may lead to rapid resolution
of the collagen sponge and failure of the graft
material.54
The flapless ridge preservation technique pro-
vides certain advantages including preservation of
blood circulation, soft tissue architecture, hard
tissue volume at the site, decreased surgical time,
minimal patient discomfort, and accelerated recu-
peration. Patients are able to resume normal oral
hygiene procedures immediately after the surgery.
Drawbacks of raising a flap and placing a mem-
brane for ridge preservation are prevented, such as
reduction of keratinized gingiva, alteration of
gingival contours, and migration of the mucogingi-
val junction due to coronal displacement of the flap
in an attempt to achieve primary closure.
As far as the dimensional stability of the ridge
with this technique is concerned, an in vivo study
reported that in sockets treated with the ‘‘socket-
plug’’ technique using anorganic bovine bone
mineral, the resorption after 3 months was limited
to 14% of the initial bone width, whereas the
control group had a resorption of 21%.55 Our results
demonstrated a similar reduction of approximately
12% in the orofacial dimension. Histologic out-
comes of the ‘‘socket-plug’’ technique comparing
allogenic and xenogenic bone grafts showed that
the allograft was completely integrated into the
newly formed bone after 3 months of healing,
696 Vol. XL /No. Six /2014
whereas the anorganic bovine bone was only
partially integrated with distinguishable graft parti-
cles remaining.56 In our case example, newly formed
bone was well trabeculized, and the particles of CPS
putty alloplastic bone substitute were bridging with
the newly formed bone.
CONCLUSION
Previous publications indicate that the alveolar
ridge resorption process can be limited. Ridge
preservation requires careful tissue handling during
and after the extraction of one or more teeth, as
well as proper use of available bone substitutes. The
‘‘socket-plug’’ technique can help the clinician to
provide the best possible outcome with the least
patient discomfort. The results of this technique
depend not only on the delicate handling of the
area but also on the resorption rate of the graft
material and its timely replacement by mature bone
capable of withstanding functional loading.
ABBREVIATIONS
CEJ: cementoenamel junction
CPS: calcium phosphosilicate
FDBA: freeze-dried bone allograft
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