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Received: 29 January 2023    Revised: 15 May 2023    Accepted: 18 June 2023

DOI: 10.1111/prd.12509

REVIEW ARTICLE

Complications following alveolar ridge augmentation

procedures

Binnaz Leblebicioglu  | Dimitris N. Tatakis

Division of Periodontology, College of Dentistry, The Ohio State University, Columbus, Ohio, USA

Correspondence
Dimitris N. Tatakis, Division of Periodontology, College of Dentistry, The Ohio State University, 305 West 12th Avenue, Columbus, OH 43210, USA.
Email: tatakis.1@osu.edu

1  |  I NTRO D U C TI O N regeneration and may also lead to material-­specific complications.

Alveolar Ridge Preservation (ARP) and Guided Bone Regeneration
(GBR) procedures have been routinely indicated to, respectively, pre-
serve and restore alveolar bony architecture following tooth loss. As
defined in the Glossary of Periodontal Terms, GBR is a surgical proce-
dure with the goal of augmenting bone volume in edentulous or peri-­
implant areas using a barrier membrane, often in conjunction with
bone grafting materials and/or biologics.2 The expected outcome of
such surgical intervention is the availability of adequate bone volume
for ideal implant fixture placement, facilitating the fabrication of an
1,3–­5
esthetically and functionally acceptable dental restoration.
available evidence indicates that these procedures are successful in
providing the desired reconstruction of the alveolar ridge.6–­11
While GBR aims for bone regeneration/augmentation in lateral,
vertical or both directions, the procedure also affects gingival tissue
phenotype, with documented postoperative changes in both gingi-
val thickness and keratinized tissue width.9 In addition, new bone
formation within the augmented tissue volume can be limited and
12,13
is not always predictable. This means that procedures aiming to
increase soft tissue quantity or improve soft tissue quality might be
needed in the course of restoring the lost ridge dimensions. Alveolar
Ridge Augmentation Procedure (RAP), defined as a procedure de-
2
signed to correct a deformed alveolar ridge, is a broader term and
often used in current literature.14 RAP may include both soft-­ and
hard-­tissue augmentation procedures. In general, and especially in
the context of dental implant therapy, these procedures require the
use of multiple biomaterials, including bone graft material together
with a barrier membrane.15,16 Although crucial for the success of
RAP, these biomaterials may present inherent limitations in bone
To overcome some of the biomaterial-­dependent limitations and
complications, several different surgical modalities have been intro-
duced in recent years.17–­23 Given the technical complexity of RAP
1
techniques, it is not surprising that postoperative complications,
either related strictly to the associated tissue manipulations or to
the applied biomaterials, are common. 24–­29 A list of possible com-
plications is presented in Table 1. In the following sections, the var-
ious complications are reviewed based on the involved tissue type,
alterations in function and aesthetics, the timing of presentation, the
type of biomaterial used, and the surgical protocol involved.
The The aim of this review is to describe possible complications due
to surgical techniques and/or biomaterials used in RAP, focusing
specifically on procedures where particulate bone grafts are used.
Modalities developed to prevent/manage these complications are
also discussed.
2  |  CO M PLI C ATI O N S BY TI S S U E T Y PE
2.1  |  Soft tissue complications
The manipultated soft tissues during RAP are the most common
source and site of postoperative complications. In particular, wound
dehiscence or wound opening during early healing phases is the most
prevalent complication25,26 and can persist for weeks, depending on
the surgical approach (Figures 1 and 2). Wound dehiscence prevalence
is proportional to the extent of the treated area (wound size) and to
the level of flap advancement.24,28 It is also more common when RAP
is performed in combination with non-­resorbable barriers, such as

Prepared for Periodontology 2000 Monograph titled: “Bone Regeneration in Implant Dentistry”. Guest-­Editor: Nikos Donos (Queen Mary University of London).

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2023 The Authors. Periodontology 2000 published by John Wiley & Sons Ltd.

Periodontology 2000. 2023;00:1–15.  |

wileyonlinelibrary.com/journal/prd     1
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2      LEBLEBICIOGLU and TATAKIS

TA B L E 1  Complications of ridge augmentation procedures.

polytetrafluoroethylene (PTFE) membrane or titanium mesh.29 In a
Soft tissue-­related complications recent study of RAP after tooth extraction, wound opening preva-

⚬ Minor/major
• Wound dehiscence
lence and size increased with time after the procedure, and wound
• Flap necrosis dehiscence influenced postoperative swelling.30 These complications
• Hemorrhage are associated with the often-­significant discrepancy between the
• Petechiae/ecchymosis existing (preoperative) soft tissue quantity and the soft tissue needed
• Hematoma formation
to accommodate (cover) the augmented ridge area, along with the dif-
• Edema/swelling
• Abscess ficulty encountered in some areas to prepare truly passive flaps. If
flap advancement and periosteal releasing incisions can be avoided,
⚬ Sinusitis
• Infection

⚬ Fistula formation
an approach that is possible with the use of suture matrices designed
and manufactured to remain exposed in the oral cavity,31–­33 then it
• Vestibular depth reduction
• Loss of keratinized tissue is possible to minimize or avoid some of these complications. Minor
or significant flap necrosis during early phases of healing (Figure  3)
Hard tissue-­related complications
can be linked to extensive and traumatic tissue manipulations, flap
• Tooth root damage
• Sinus wall damage tension, periosteal releasing incisions, and tissue distention from
the added graft materials and the postoperative swelling. In general,
⚬ Osteomyelitis
• Bone necrosis
this is due to compromised flap blood supply. It is mostly limited to
• Failure to regenerate adequate bone volume
the marginal (crestal incision) aspect of the flap24,28–­30 (Figure  4).
• Mandibular fracture
However, it may also lead to loss of keratinized tissue (width of at-
Neurosensory complications
tached gingiva), although this complication may occur in the absence
• Paresthesia/sensory disturbances
of flap necrosis as well17,30 (Figure  5). The aforementioned applica-
• Pain/severe discomfort
tion of techniques where flap advancement and periosteal releasing
Material-­related complications
incisions are avoided, along with use of barrier membranes that can

⚬ Early/late
• Membrane exposure
remain exposed to the oral environment, allows for better preserva-
tion of keratinized tissue dimensions.31–­33 Additionally, scar or fibrous
⚬ Loss of membrane fixation
• Membrane fixation complications
adhesion formation may also develop after RAP.17,18 Postoperative
⚬ Fracture of fixation devices
⚬ Dislodgment of fixation devices
infections can occur18,24,25 and could lead to abscess or purulent exu-

⚬ Swallowing of fixation devices

date26 formation. In more rare instances, fistula formation with com-
munication to the extraoral environment may also occur.34
• Graft material/fixation device exposure
• Graft material infection Soft tissue related complications listed above can be observed
• Graft material loss more often when pre-­surgical tissue phenotype is thin.35,36 Based on
• Suture loss the literature, the threshold value to describe thin gingiva is <1 mm
• Non-­allergic tissue reaction to materials (membrane, graft,
thickness or metal probe color showing through gingiva.37 This clas-
fixation devices, sutures)
• Allergic reaction to materials (membrane, graft, fixation devices, sification is generally used to described gingiva around natural teeth
sutures) and has been modified for edentulous ridges and around implant
Other complications supported restorations.38 Keratinized oral mucosal tissue has multi-
• Trismus/Mouth opening limitations functional importance, including protection from mechanical trauma
• Chewing difficulties and vestibular depth space maintenance. Thick gingival phenotype,
• Prescription medication-­related complications i.e., gingiva with greater thickness (>1 mm) and keratinized tissue
• Aesthetic complications
width (≥2 mm),39 has been critical for the success of guided bone

F I G U R E 1  Early wound dehiscence

following application of a resorbable
membrane. Clinical appearance at surgery
completion (A) and 10 days postoperative
(B).
LEBLEBICIOGLU and TATAKIS |
      3

F I G U R E 2  Early wound dehiscence following application of a resorbable membrane. Clinical appearance at surgery completion (A) and
at 7 (B) and 14 days postoperative (C). Compare with Figure 1, where the extent of the treated area was much more limited (smaller wound
size).

F I G U R E 3  Early flap necrosis and

healing. Clinical appearance at surgery
completion (A), 10 days (B), 3 weeks (C),
and 3 months (D) postoperative. Note
signs of surgical trauma mesial to the
canine (A), corresponding area of surface
necrosis (B), and progressive wound
healing (C, D). Also note absence of
membrane exposure.

F I G U R E 4  Early flap necrosis. Clinical

appearance at surgery completion (A),
and 3 weeks (B) postoperative. Note signs
of surgical trauma mesial to the canine
(A) and corresponding area of surface
necrosis and resorbable membrane
exposure (B).

regeneration/augmentation procedures mainly by preventing barrier
membrane exposure and/or complications such as development of
abscess (gumboil) corresponding to the location of the fixation screws
9,40
indicated to stabilize a barrier membrane (Figure 6). Lack of kerati-
nized tissue width can be addressed by phenotype modification pro-
cedures, such as free gingival grafting, prior to the ridge augmentation
procedure (see section below on phenotype modification).
Other common soft tissue complications following RAP are
related to blood extravasation and include the development of
hemorrhage, hematomas, and petechiae/ecchymoses20,28 (Figure 7).
Often related to the aforementioned complications is the develop-
ment of postoperative edema and swelling, 20,21,23,30,41 although it
is not necessarily associated with hematoma or petechiae devel-
opment. Evidence originating solely from impacted third molar ex-
traction studies indicates that it is possible to limit postoperative
swelling with pre-­emptive use of prescription anti-­inflammatory
medication42,43; however, there are no pertinent studies in the RAP
literature.
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4      LEBLEBICIOGLU and TATAKIS
F I G U R E 5  Loss of keratinized tissue width and coronal advancement of the mucogingival junction. Clinical appearance before tooth
extraction and ridge augmentation surgery (A) and at 6 weeks (B) postoperative. Note keratinized tissue width reduction on the left lateral
incisor, in the absence of any wound dehiscence or other soft tissue complication.
F I G U R E 6  Fixation screw prominence, at 1 month postoperative.
Postoperative swelling and flap advancement along with large
graft volume can lead to considerable vestibular depth reduction44
itself a potentially significant, although usually temporary in nature,
complication. This is often accompanied by significant coronal ad-
vancement of the mucogingival junction (Figure 8).
2.2  |  Hard tissue complications
Ridge defects that are lacking buccal bone plate are generally de-
scribed as non-­self-­contained ridge defects.45,46 These can be ridge
deficiencies in the horizontal (buccal-­lingual) direction, deficiencies
in the vertical (apical-­coronal) direction or combination type defects
presenting dimensional deficiencies in both directions.47,48 Compared
to a self-­contained ridge defect that is surrounded by four bony walls
(example: alveolar socket), non-­self-­contained ridge defects require
additional surgical manipulations such as decortication of the existing
46,47
bone walls, placement and fixation of a barrier membrane under
the flap prior to bone grafting and, potentially, use of tenting screws
to create and maintain space during healing.49 In addition, the need for
non-­resorbable barrier membranes is more crucial in treating these
types of defects to create and maintain the space.50 Thus, higher
rates of post-­R AP complications have been reported with non-­self-­
contained large size ridge defects. These are generally related to loss
of space maintenance by a barrier membrane and/or a tenting screw
becoming loose under the flap, and bone graft becoming dislocated
51
due to barrier membrane movement. Inadequate bone regeneration
may also be due to lack of angiogenesis, especially deep in the core
and/or at the external layer of the grafted volume.52 This, in turn,
may cause lack of expected volume augmentation (Figure 9) without
causing too much discomfort during healing.53 Similarly, the disloca-
tion of augmented bone volume at the time of implant placement
due to lack of complete integration with pre-­existing bone has also
been reported.54 In addition, post-­R AP infection due to bone graft
dislocation, loose barrier membrane or fixation screw, and/or residual
infected tissues from extracted teeth can be observed.24,25,28–­30,34
These hard tissue complications are generally co-­existent with soft
tissue related complications (e.g., flap necrosis, wound opening and/
or dehiscence together with infection).
2.3  |  Nerve tissue complications
Any surgical tissue manipulations, and occasionally even just the
application of local anesthesia, can lead to neurosensory compli-
cations, including pain and/or paresthesia or other sensory dis-
turbance, such as increase in adjacent tooth sensitivity.55 Pain is
frequently reported by patients during the first few postoperative
days, 23,30,56 but it may persist for the first couple of weeks.30,36,47,48
Recent evidence indicates that both wound opening and duration
of surgery affect postoperative pain at 1 week.30 Postoperative pain
after GBR has a negative impact on the patients' quality of life.30
When specific nerves are affected in the course of a GBR procedure,
the ones most likely to be injured are the nerves that can be readily
accessed during extensive flap elevation and/or periosteal release,
e.g., the mental nerve, 29 the infraorbital nerve,57 and the lingual
nerve.58 Careful flap elevation and proper periosteal releasing tech-
nique, including appropriate incision design, will minimize the risk of
trauma to these nerves.58–­62
3  |  CO M PLI C ATI O N S I N FU N C TI O N A N D
A E S TH E TI C S
3.1  |  Functional complications
In addition to post-­R AP pain and swelling, some functional compli-
cations related to temporomandibular joint disorders and difficulty
in mouth opening, as well as chewing and phonetic functions, have
LEBLEBICIOGLU and TATAKIS |
      5

F I G U R E 7  Early postoperative
hematoma. Clinical appearance at
surgery completion (A) and at 1 week
postoperative (B). White arrow points to
hematoma formed on inner aspect of the
lip, yellow arrow points to hematoma on
alveolar mucosa. Note also minor wound
dehiscence along the crestal incision line.

F I G U R E 8  Vestibular shortening and

coronal advancement of the mucogingival
junction. Clinical appearance before flap
elevation (A), and at surgery completion
(B).

F I G U R E 9  Failure of bone regeneration. Clinical presentation prior to treatment (A), at surgery completion (B), and 6 months
postoperative (C).

been reported in the literature. 27,30,63 The discomfort/contraindica-
tions of wearing removable temporary restorations following large
64
size RAP is also routinely observed. Although proper surgical
technique, minimal tissue trauma, and adequate postoperative pre-
scription regimens could help reduce the occurrence, severity, and
impact of these functional complications, such measures are unlikely
to completely eliminate postoperative chewing and phonetic diffi-
culties. Consequently, patients should be adequately informed of
the potential to experience these functional limitations during the
postoperative period.
Large flaps may result in compromised interdental/interimplant
papilla retention and/or reconstruction. These aesthetic complica-
tions may not become evident until after prosthesis fabrication is
initiated or even after completion of the restorative phase of implant
therapy. The impact of the aforementioned aesthetic complications
will vary by patient, depending on the patient's smile line height and
aesthetic concerns. As with the functional complications reviewed
above, patients should be adequately informed of the potential to
face these aesthetic compromises as a result of the procedure and
its outcomes.

3.2  |  Aesthetic complications 4  |  CO M PLI C ATI O N S BY TI M E O F

Soft and hard tissue complications, as outlined above, especially
ones related to deficient tissue quantity and quality, may lead to aes-
thetic complications, even if they do not prevent implant placement.
For example, vestibular shortening and the concomitant coronal
positioning of the mucogingival junction may compromise aesthet-
ics. (Figure 10). Poor bone regeneration outcomes, i.e., hard tissue
complications, in the aesthetic zone may lead to aesthetic compli-
cations because of the ensuing compromised implant positioning.
O CC U R R E N C E
4.1  |  Surgical complications (at time of surgery)
In general, the control of periodontal/peri-­apical infections is a pre-
requisite to perform any regenerative procedure. However, this is
not always possible when there is an indication for GBR immediately
after tooth extraction due to concerns of remaining buccal plate
collapse.65 Nevertheless, severely infected soft and/or hard tissues
 |
6      LEBLEBICIOGLU and TATAKIS
may present a major limitation to performance of RAP immediately
following tooth extraction.66
Proximity to major anatomical landmarks such as the maxillary
sinus floor, floor of nasal cavity, prominent incisive or mandibular
canal, etc., during tooth/root extraction, degranulation, and de-
cortication, and even during fixation screw placement, may result
in violation of these structures which may induce damage resulting
in intra-­operative vascular and/or neurosensory complications.58,67
Furthermore, such intra-­operative complications and/or simply the
opening of and communication with these anatomical spaces/struc-
tures may force aborting the bone grafting phase of the procedure.68
Biomaterial failures, e.g., fixation screw fracture, may also occur
during the surgical procedure (Figure 11).
Presence of a shallow vestibule, often the result of severe bone
loss and alveolar ridge collapse, creates a major limitation for ridge
augmentation procedures due to limited available ridge height to
44
stabilize the barrier membrane and bone graft. The lack of kera-
tinized tissue and the looseness/mobility of cheek mucosa create
additional challenges during surgery and may lead to complications
in terms of access and stability of regenerative biomaterials and/or
flaps.44
As ridge dimensions diminish due to bone resorption, bone qual-
ity is also changing, characterized by loss of trabecular bone and dis-
69
proportional increase in cortical bone, especially in the mandible.
This, by itself, may cause some complications such as limited blood
supply, despite decortication, and greater difficulty to insert fixation
devices. More common in maxillary sites, the presence of soft bone
can make stabilization of fixation or tenting screws challenging, if
not impossible.70
As mentioned earlier while covering soft tissue related complica-
tions, wound closure plays a crucial role in the successful outcomes
of RAP, especially when non-­resorbable barrier membranes are indi-
9,24–­26,51
cated. However, achieving tension free primary wound clo-
sure is not always possible, depending on the severity of the ridge
24
collapse and lack of thick gingival tissues. Additional efforts and
approaches used to achieve adequate flap release may significantly
F I G U R E 1 0  Vestibular shortening and
coronal advancement of the mucogingival
junction, compromising aesthetics. Clinical
appearance after tooth extraction and
before flap elevation (A), and at surgery
completion (B).
F I G U R E 1 1  Intraoperative fixation
screw fracture (A). The broken screw was
recovered (B) and replaced.
traumatize the flap blood supply and/or result in excessive bleeding/
hematoma formation under the flap. 24–­28
4.2  |  Early post-­operative complications (during 1
to 4 weeks)
Early post-­operative complications, especially soft tissue ones,
tend to be more impactful than late complications. Wound open-
ing is the major early healing complication reported following al-
veolar ridge augmentation procedures. 27 Assuming adequate flap
advancement and achievement of primary closure, this complication
occurs mainly due to post-­operative edema and/or suture loosen-
ing. 28 Patients may report some discomfort and pain especially if
they experience significant swelling.30,63 Edema may also induce
space formation between flap and barrier membrane and/or bone
graft. This, in turn, may cause an increase in inflammatory response
and suppuration.71 If the wound opening is large, patients may de-
velop infection. This, in turn, may induce barrier membrane loosen-
ing and graft dislocation. 25–­27 Wound exposure also causes faster
barrier membrane resorption when resorbable membranes are used
and increases the likelihood of contamination when non-­resorbable
membranes are used72 (Figures  12 and 13). In some cases, wound
opening does not cause infection, but the barrier membrane may
not function well as a barrier against epithelial migration due to ex-
posure25–­27 (Figure 13). This, in turn, causes bone graft material en-
capsulation by newly forming granulation tissue and/or graft particle
migration into the soft tissues. 25–­27
Wearing a removable provisional restoration may induce early
wound opening.64,73 Even in the absence of wound exposure, a re-
movable provisional restoration negatively affects alveolar ridge
augmentation outcomes due to lateral movements, pressure, and/or
rubbing of the buccal flange onto grafted sites, which may result in
dislocation of the grafted material.73,74
The aforementioned RAP soft tissue complications related to
blood extravasation (hemorrhage, hematomas, and petechiae/
LEBLEBICIOGLU and TATAKIS
ecchymoses), 20,27 as well as the often-­reported edema and
20–­23,36
swelling, are also common early postoperative complica-
tions, manifesting within the first few days and weeks after the
procedure.
4.3  |  Late post-­operative complications (4 weeks to
implant placement)
RAP outcomes are not always predictable due to possible late com-
plications that are clinically difficult to detect at an earlier time
point and end up being identified at implant placement. It is well
established that ridge augmentation in a vertical direction is less
75–­77
predictable than in a horizontal direction. This is mainly due
to limitations of the existing scaffold materials and lack of angio-
genesis at distances away from the host bone surface (central core
and external layer of the total graft volume).78 These late complica-
tions can be due to graft mobility, resulting from loosening of the
fixation screws, stabilization sutures and/or migration of tenting
screws, and also possibly due to incomplete soft tissue exclusion
by the barrier membrane. One such major late complication that is
reported in some studies is the lack of integration between the re-
generated bone volume and the host bone surface; although ridge
F I G U R E 1 2  Early wound dehiscence and exposure of
non-­resorbable (polytetrafluoroethylene) membrane. Clinical
appearance at 4 weeks postoperative.
F I G U R E 1 3  Early exposure of titanium-­reinforced membrane and progression over time. Clinical appearance at 5 days (A), 2 weeks (B),
and 7 weeks postoperative (C). Note the progressive increase in membrane exposure and the evident accumulation of dental biofilm on the
membrane by week 7 (C).
|
      7
augmentation may be viewed as successful, based on augmented
volume, the regenerated portion may dislodge from the host bone
surface during the ostectomy and/or the osseocondensation proce-
dure used to prepare the implant site. 27
In addition to hard tissue related late complications, soft tissue
defects may develop late, following wound opening during post-­R AP
wound healing. Thus, wound opening, the major early RAP compli-
cation, negatively affects both the hard and soft tissue outcomes
of alveolar ridge augmentation, i.e., it can both reduce the regen-
erated volume and can cause significant soft tissue defects (loss
of attached/keratinized gingiva, loss of vestibular depth, scarring,
etc.). 24–­27 However, even in the absence of wound opening, late soft
tissue complications, such as reactions to the materials used, are
possible (Figure 14).
When they occur in the aesthetic zone, many of the complications
addressed in the paragraphs above may also lead to aesthetic com-
plications79 that can compromise the final outcome, after comple-
tion of the restorative treatment phase, even if, or especially when,
implant placement is possible without additional interventions.
5  |  CO M PLI C ATI O N S BY B I O M ATE R I A L
T Y PE
5.1  |  Bone graft materials
Various bone graft substitutes are currently available in particulate
form. Allografts and xenografts can be used as a single material of
choice, or they can be mixed with autograft and/or with each other,
as well as with various biologics. Regardless of the type of bone graft
material, two major concerns in relation to bone graft materials and
their usage in RAP are lack of osteogenesis and loss of material dur-
ing healing. 23,80 Allografts and xenografts are mainly osteoconduc-
tive in nature (bone grows on existing surface without the material
itself turning into bone [osteogenesis] and/or without any induction
ability to recruit and stimulate immature cells [osteoinduction]).81
For this reason, such graft material may become loose during heal-
ing. 27,28 Similarly, and particularly when treating large size defects, a
significant portion of these grafts remains as residual graft material
incorporated within the augmented new bone.82
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8      LEBLEBICIOGLU and TATAKIS
There is insufficient information available on the long-­term
behavior/maintenance of these residual particles within the aug-
mented ridge and/or at the interface of implant and regenerated
bone. Recent evidence suggests that, in a few patients (<10% of
those receiving the materials), certain bone allografts could elicit
immunological responses, which were detected 4 months postop-
eratively; the patients who developed positive reactions after the
grafting procedure showed significantly increased levels of IL-­1α,
IL-­1β, and TNF-­α in biopsies, delayed wound healing after the graft-
ing procedure, and greater resorption of the grafted material, which
83
was confirmed at time of implant placement. Although these pa-
tients required some additional horizontal augmentation at time of
implant placement, they showed no other clinical differences from
the rest of the patients; the study results also raised the possibility
that grafts prepared from multiple donors might be more likely to re-
sult in such immunological incompatibility than grafts prepared from
single donor.83 It has also been reported that bone grafts, when in
contact with major nerves, may act as an irritant and lead to neuro-
84
sensory complications.
5.2  |  Barrier membranes
Barrier membranes used in RAP are designed to stabilize the par-
ticulate bone graft and create/maintain space during the healing
phase, while excluding gingival connective tissue and epithelium
16
from the site. However, they often become exposed due to wound
opening and soft tissue dehiscence. 27 This can occur with both re-
24–­27
sorbable and non-­resorbable membranes. Among the different
barrier membranes available, cross-­linked resorbable membranes,
like non-­resorbable membranes, are more form-­stable (i.e., tend to
retain their original shape), and thus more likely to result in exposure,
especially when the overlying tissues are thin. Proper membrane
F I G U R E 1 4  Late soft tissue
complications in the absence of early
wound dehiscence. Clinical appearance
of the buccal (A) and lingual (B) aspect
at 3.5 months after use of autologous
bone, non-­resorbable membrane, and
two fixation screws placed on the buccal
aspect. Patient was asymptomatic and
there was minimal, if any, exudate elicited
upon attempt to drain these lesions.
The same granulation tissue lesions
remained on the buccal (C) and lingual
(D) at 5 months postoperative, when the
patient presented for membrane removal
(Courtesy of Dr. Priyanka Pitchumani).
contouring (e.g., trimming to avoid sharp angles) and fixation will
help minimize flap perforation by such membranes.
When a resorbable membrane is exposed, its resorption rate is
typically faster, thus not allowing sufficient time for complete bone
healing and collapse of the space is routinely observed. 28,50 When
a non-­resorbable membrane is exposed, the risk of infection, due
to bacterial contamination, is higher. 26,28,85 The management of ex-
posed non-­resorbable membranes varies by the level of exposure
(small, i.e., ≤3 mm, or large, >3 mm), the accompanying clinical con-
dition of the overlying soft tissues (absence or presence of puru-
lent exudate) and the underlying bone graft (presence or absence
of infection), and the timing of the exposure (early or late). 26 The
above parameters will dictate the preferred management, which
can range from simple measures (antimicrobial rinse or gel, weekly
monitoring and professional debridement, and removal at 6–­8 weeks
or later) to more aggressive approaches (antibiotic prescription and
immediate membrane removal, bone graft removal). 26 Soft tissue
reactions following exposure of a resorbable membrane tend to be
lesser compared to the tissue reactions following exposure of a non-­
resorbable membrane, at the same postoperative time point (com-
pare Figures 1B, 2C and 4B against Figures 13B and 15B). However,
recent systematic reviews indicate that when horizontal ridge aug-
mentation is performed there is no statistically significant associa-
tion between the incidence of a specific complication and the type
(resorbable or non-­resorbable) of membrane used,86 while when
vertical ridge augmentation is performed the incidence of healing
complications (membrane exposure) is greater for resorbable mem-
branes. 28 These findings suggest that barrier membrane-­associated
complications depend on both the nature of the material (resorb-
able or non-­resorbable) and the type of defect/procedure where
they are used. Similarly, extracellular fluid build-­up under the bar-
rier membrane may cause its dislocation. Thus, loss of graft along
with space collapse are routinely observed. 28,29 With that, exposed
LEBLEBICIOGLU and TATAKIS |
      9

non-­resorbable barrier membranes have to be removed earlier than
28,29
at the ideal healing time.
The complications associated with non-­resorbable membranes
differ by material type; complications following exposure of ex-
panded PTFE (e-­PTFE) membranes (with or without titanium rein-
forcement) tend to be more significant and more difficult to manage
than those following exposure of dense PTFE (d-­PTFE) membranes.
As mentioned above, wound dehiscence is more common when non-­
resorbable barriers, such as PTFE membranes or titanium meshes,
29
are used (Figures 15 and 16). In addition, soft tissue scarring and
defects can develop due to exposure of the non-­resorbable barrier
membrane29,35 which can necessitate several corrective soft tissue
surgeries prior to a second RAP attempt. 24,29
Among resorbable barriers, cross-­linked matrices are, in general,
better able to withstand exposure to the oral cavity than non-­cross-­
linked ones; thus, they can be left intentionally exposed when the
surgical approach aims to minimize flap advancement (see section
above on soft tissue complications).33
5.3  |  Fixation/tenting screws
As mentioned above, screw fracture can occur during placement,
especially in dense cortical bone (Figure 11). During healing, tenting
and/or fixation screws may become prominent and cause discom-
fort (Figure 6). They may also penetrate the soft tissue and become
exposed (Figure 17).
6  |  CO M PLI C ATI O N S BY S U RG I C A L
PROTO CO L /M O DA LIT Y
Various surgical protocols have been developed to modify what is
known as conventional ARP or GBR. Most of these modifications
aim to prevent some of the complications covered in the sections
above. Each of these modalities have specific indications yet some
major limitations themselves. As with every surgical procedure, any
medications (e.g., analgesics, antibiotics, etc.) prescribed in con-
junction with RAP may lead to medication-­specific adverse effects,
which should also be considered as possible complication.
6.1  |  Alveolar Ridge Preservation (ARP) and
modifications
Alveolar Ridge Preservation (ARP), also known as socket preserva-
tion, prosthetic socket preservation, or ridge augmentation, was
first coined by Cohen in 1988. 87 It involves placement of a bone

F I G U R E 1 5  Early exposure of
titanium mesh. Clinical appearance
during placement (A) and at 3 weeks (B)
postoperative.

F I G U R E 1 6  Early wound dehiscence

and exposure of non-­resorbable
(polytetrafluoroethylene) membrane.
Clinical appearance at surgery completion
(A) and at 3 weeks postoperative (B).

F I G U R E 1 7  Tenting screw exposure.

Clinical appearance during placement (A)
and at 2 months (B) postoperative.
 |
10      LEBLEBICIOGLU and TATAKIS
grafting material into the post-­extraction socket and utilization of
a resorbable or non-­resorbable membrane barrier to contain the
graft and provide space maintenance during healing. Although
reports documenting bone regeneration with the use of mem-
brane barrier alone exist, 88,89 most of the studies investigate the
90
use of a specific bone graft material with/without a membrane.
There is also significant interest to study the possible beneficial
effects of biologics mixed with the graft material and/or used to
seal the orifice of the socket.91 This procedure aims to prevent
post-­extraction alveolar bone loss. ARP serves to preserve the
dimensions of the alveolus by a) stabilizing the clot and b) pro-
viding a scaffolding for new bone formation92 to minimize poten-
tial reduction in bone volume. Despite these advantages, ARP is
contraindicated in sites where existing infection/inflammation
cannot be controlled through tooth extraction and mechanical
debridement.93,94 Similarly, primary wound closure is not a goal
of conventional ARP since flaps are not elevated, in order to pre-
vent surgical trauma and disturbance of blood supply to an already
compromised buccal bone. Thus, there is the risk of biomaterial
contamination and dislocation during wound healing.
The complications reported following ARP include soft tissue in-
flammation, postoperative pain and discomfort, edema, erythema,
possible infection, loose/exfoliated graft particles, membrane ex-
posure, membrane exfoliation, loss of membrane integrity (break-
63,95
down), and deficient socket fill. Other reported complications
post ARP include gingival recession, tooth sensitivity, and dry
socket.63 Several minimally invasive surgical techniques, which aim
to support/preserve the buccal plate in the anterior sextant, have
been developed.47,96 Although it has been suggested that perfor-
mance of minimally invasive procedures will help reduce incidence of
postoperative complications,97 there is limited evidence to indicate
that minimally invasive techniques alter or reduce the anticipated
post-­ARP morbidity and patient-­reported outcomes.98
Based on the available evidence, most of the consensus re-
ports99,100 support performing ARP following tooth extraction, espe-
cially in the aesthetic zone, if immediate or early implant placement
101
is contraindicated due to site-­ and/or patient-­specific factors. It is
well-­accepted that ARP preserves alveolar ridge height but does not
completely prevent ridge width loss; this can be generally tolerated
well, given that the implant has to be placed more palatally than the
extracted tooth root and in an upright position as perpendicular as pos-
sible to the occlusal plane. The available evidence does not allow iden-
tification of a superior approach for ARP.91 However, combinations of
allogenic or xenogenic particulate grafts with an absorbable collagen
membrane or sponge provide the most favorable outcomes.91 Recent
systematic reviews indicate that despite significant differences in clin-
ical outcomes (preservation of ridge width and height) among various
graft materials,15 there are no significant differences from a histologi-
cal/histomorphometric perspective (new bone formation and residual
102
graft particles) ; it was also noted that the quality of the available
evidence is limited.102 Nonetheless, minimally invasive surgical proto-
cols with resorbable materials that are easy to apply in the presence of
limited surgical access should be chosen whenever feasible.103
6.2  |  Guided bone regeneration (GBR) and
modifications
Guided bone regeneration (GBR) is an essential treatment modality
for implant dentistry because it provides satisfactory bone quantity
for implant placement in sites that, prior to the procedure, may have
had insufficient bone to adequately house an implant fixture.104
Predictable positive GBR treatment outcomes require correct indi-
cation with use of ideal biomaterial(s) based on alveolar ridge de-
fect severity and configuration.105 Wang and Boyapati described
the “PASS” principle to be followed for predictable regeneration of
bone: primary closure of the wound, angiogenesis to allow for suf-
ficient blood supply (nutrients and undifferentiated mesenchymal
cells) to the graft, space maintenance for exclusion of epithelial and
connective tissue cells during bone healing, and stability of the sur-
gical site.51 As defect size and shape shift from a single edentulous
site with ample gingival tissue contours and minor width deficiency
at the buccal aspect of the ridge to more severe forms, including soft
tissue deficiency with bone resorption and multiple adjacent missing
teeth, to complex defects that are deficient at both buccal-­palatal
and apical-­coronal dimensions, surgical modalities and biomaterial
choices should be reconsidered.36 Minimally invasive surgical pro-
tocols with a significant emphasis on the role of soft tissue on bone
regeneration are often discussed in relation to the aesthetic zone.106
Combined ridge defects with deficiency at both vertical and
horizontal dimensions co-­exist with soft tissue deficiencies. Surgical
treatment requires advanced techniques and the use of more than
one type of biomaterial. This, in turn, complicates wound healing
with a higher prevalence of complications such as wound opening,
material loosening, infection and higher percentage of residual graft
material incorporated into regenerated bone volume.107 Defect size
also seems to affect the rate of complications, with larger defects
apparently associated with more complications. 24,26
It is well known that, in general, GBR provides predictable ridge
width augmentation.1,108 However, it has much more limited success
in augmenting vertical dimensions.108 Various graft materials and bar-
rier membranes have been developed to overcome this limitation.105
Most of the allografts and xenografts are osteoconductive with very
limited osteoinductive potential.109 Because of this limitation, biologic
factors have been developed to be combined with particulate bone
graft. Among those, blood-­derived products (e.g., platelet-­rich fibrin,
PRF), amelogenins (Emdogain®), bone morphogenic proteins, PDGF,
FGF2, Teriparatide, Radotermin (GDF-­5), mesenchymal stem cells of
various origins and gene therapy (specifically osteoprotegerin, BMP2,
BMP7, LMP3) have been investigated with variable results.110
Some type of barrier membrane is always necessary to stabilize
the bone graft during GBR. These membranes are generally classified
as resorbable and non-­resorbable types. Stability of the graft mate-
rial and/or preservation of the space are the main challenges when
treating complex ridge defects with GBR. Placing tenting screws is
an approach developed for this purpose.111 However, tenting screws
may become exposed during wound healing, especially if a resorb-
able membrane is used.111 In addition, they may become dislocated,
LEBLEBICIOGLU and TATAKIS
resulting in barrier membrane loosening and/or collapse. This, in turn,
could cause loss of graft material and increase the risk of wound open-
ing/dehiscence.111 There are two well-­documented GBR modifica-
tions to avoid these types of complications: ridge split and segmental
distraction techniques. However, these are classified as advanced sur-
gical techniques and should be considered only for complex ridge de-
ficiencies due to the reported high risk of major complications.112–­117
7  |   PR E V E NTI O N O F S PEC I FI C
CO M PLI C ATI O N S BY PH E N OT Y PE
M O D I FI C ATI O N
The role of soft tissue in primary wound closure, angiogenesis, graft
stability and space maintenance has been heavily covered throughout
this review. Thus, socket and ridge defects should be evaluated not
only for hard tissue volume and dimensions but also for gingival tissue
thickness, keratinized tissue dimensions, vestibular depth, and aber-
rant frenum presence. Thin soft tissue phenotype can be modified to
thick phenotype by means of subepithelial connective tissue graft or
free gingival graft procedures. The latter is preferred in cases of thin
118
phenotype with lack of keratinized tissue. Presence of keratinized
gingiva is important not only for wound management following bone
regenerative procedures but also for the predictable maintenance of
future peri-­implant tissue health.119 Vestibular depth should be eval-
uated as part of both the surgical and restorative treatment plans.
It is well documented that any ARP/GBR procedure that requires
major coronal advancement of the buccal flap to obtain wound clo-
sure will create a shallow vestibular depth and narrower keratinized
95
gingiva. Thus, vestibular deepening procedures together with free
gingival graft may be indicated prior to advanced GBR procedures.120
Similarly, any existing aberrant frenum should be corrected through a
frenectomy procedure in order to eliminate frenum pull and thus pre-
vent wound opening during the early phases of post-­GBR healing.121
Onlay soft tissue grafts may also be indicated, especially to increase
soft tissue thickness at the alveolar crest level, allowing for scalloped
morphology, i.e., better aesthetics, around the crown margins.122
There is significant interest to develop minimally invasive surgical
techniques to augment soft tissue contours prior to or during bone re-
generative procedures. One example is the tunneling procedure. It can
be used to create thick phenotype by placing and stabilizing a subep-
ithelial connective tissue graft through a tunnel prepared at the buc-
cal aspect of the ridge.123 A tunnel, created through a single vertical
incision, may be used to deliver a resorbable membrane together with
bone graft without raising a conventional full thickness flap, which re-
quires a crestal incision,124,125 and should be considered for GBR in
anatomical sites at higher risk of wound opening (e.g., strong lip pull).
8  |   CO N C LU S I O N S
Ridge augmentation procedures (RAP), developed to treat alveo-
lar bone volumetric and dimensional deficiencies following tooth
|
      11
extraction and prior to dental implant placement by using particu-
late bone graft substitutes have, in general, acceptable short-­ and
long-­term outcomes. However, intra-­ and post-­operative compli-
cations may be common, and occasionally severe, and may reflect
challenges at both soft and hard tissue levels. Complications such
as wound opening, soft tissue dehiscence during healing, compro-
mised blood supply, graft dislocation and graft and barrier mem-
brane loosening and space collapse are often observed when RAP
is performed to treat complex ridge defects. Reduction or avoid-
ance of such complications requires thorough diagnostic assess-
ment, proper surgical planning, appropriate technique and material
selection, and careful technical execution of the indicated surgical
procedure.
AC K N OW L E D G M E N T S
The authors thank Dr. Andreas Parashis and Dr. Shaun Rotenberg
for their constructive criticism on early drafts of this article, Dr.
Aakash Mehandru for his assistance with bibliographic information,
and Dr. Priyanka Pitchumani for generously sharing the clinical im-
ages for Figure 14. The authors thank Ms. Laura McCallister for her
expert editorial assistance. This work was supported by The Ohio
State University, College of Dentistry, Division of Periodontology,
which also provided access to its clinical image archive, an invaluable
source of material used to illustrate this article.
DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing not applicable –­no new data generated.
ORCID
Binnaz Leblebicioglu  https://orcid.org/0000-0002-2303-7717
Dimitris N. Tatakis  https://orcid.org/0000-0001-6327-3610
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How to cite this article: Leblebicioglu B, Tatakis DN.
Complications following alveolar ridge augmentation
procedures. Periodontol 2000. 2023;00:1-15. doi:10.1111/
prd.12509