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Post-extraction dimensional changes: A systematic review and meta-analysis

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DOI: 10.1111/jcpe.13390

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Received: 26 June 2020    Revised: 9 October 2020    Accepted: 12 October 2020

DOI: 10.1111/jcpe.13390

S Y S T E M AT I C R E V I E W

Post-extraction dimensional changes: A systematic review and

meta-analysis

Emilio Couso-Queiruga1  | Sandra Stuhr1  | Mustafa Tattan1  |

Leandro Chambrone1,2,3  | Gustavo Avila-Ortiz1

1
Department of Periodontics, University
of Iowa College of Dentistry, Iowa City,
IA , USA
2
Graduate Dentistry Program, Ibirapuera
University, São Paulo, Brazil
3
Unit of Basic Oral Investigations, School
of Dentistry, Universidad El Bosque,
Bogotá, Colombia
Correspondence
Gustavo Avila-Ortiz, Department of
Periodontics, University of Iowa College of
Dentistry, 801 Newton Road, Iowa City, IA
52242, USA.
E-mail: gustavo-avila@uiowa.edu
Abstract
Aim: To analyse the evidence pertaining to post-extraction dimensional changes in
the alveolar ridge after unassisted socket healing.
Materials and Methods: The protocol of this PRISMA-compliant systematic review
(SRs) was registered in PROSPERO (CRD42020178857). A literature search to iden-
tify studies that fulfilled the eligibility criteria was conducted. Data of interest were
extracted. Qualitative and random-effects meta-analyses were performed if at least
two studies with comparable features and variables reported the same outcome of
interest.
Results: Twenty-eight articles were selected, of which 20 could be utilized for the
conduction of quantitative analyses by method of assessment (i.e. clinical vs radio-
graphic measurements) and location (i.e. non-molar vs molar sites). Pooled estimates
revealed that mean horizontal, vertical mid-facial and mid-lingual ridge reduction as-
sessed clinically in non-molar sites was 2.73 mm (95% CI: 2.36–3.11), 1.71 mm (95%
CI: 1.30–2.12) and 1.44 mm (95% CI: 0.78–2.10), respectively. Mean horizontal, verti-
cal mid-facial and mid-lingual ridge reduction assessed radiographically in non-molar
sites was 2.54 mm (95% CI: 1.97–3.11), 1.65 mm (95% CI: 0.42–2.88) and 0.87 mm
(95% CI: 0.36–1.38), respectively. Mean horizontal, vertical mid-facial and mid-lingual
ridge reduction assessed radiographically in molar sites was 3.61 mm (95% CI: 3.24–
3.98), 1.46 mm (95% CI: 0.73–2.20) and 1.20 mm (95% CI: 0.56–1.83), respectively.
Conclusion: A variable amount of alveolar bone resorption occurs after unassisted
socket healing depending on tooth type.

KEYWORDS
alveolar bone loss, bone resorption, tooth extraction

1   |  I NTRO D U C TI O N maintained in a status compatible with adequate aesthetics, func-

tion and/or health, or for strategic reasons (Kao, 2008; Tonetti
The main goal of dental therapy is to enhance and maintain the et al., 2000 ). Beyond its potential impact in quality of life, tooth
general health and well-being of patients (Chapple & Wilson, extraction causes a local physiologic disruption that results in an
2014). Dental extraction is indicated when teeth cannot be initial inflammatory response and, subsequently, a variable degree

© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

J Clin Periodontol. 2021;48:127–145. |

wileyonlinelibrary.com/journal/jcpe     127
 |
128      COUSO-QUEIRUGA ET AL.
of alveolar ridge atrophy, which is primarily related to bone resorp-
tion (Araujo & Lindhe, 2005; Cardaropoli et al., 2003; Evian et al.,
1982; Trombelli et al., 2008). Numerous pre-clinical and clinical
studies have reported that most of the bone remodelling occurs
within the first few weeks after tooth extraction and it is more
accentuated on the facio-coronal aspect of the ridge (Araujo &
Lindhe, 2005; Avila-Ortiz et al., 2020 ; Chappuis et al., 2013 , 2015;
Discepoli et al., 2013).
Predicting the extent and magnitude of post-extraction dimen-
sional changes in function of specific patient and site characteris-
tics is particularly important to make judicious clinical decisions
when tooth replacement therapy is planned and alveolar ridge
preservation, with or without immediate implant placement, is
being considered (Avila-Ortiz et al., 2019; Clementini et al., 2019).
Clinical evidence indicates that some phenotypic factors may influ-
ence bone resorption patterns (Avila-Ortiz et al., 2020 ; Chappuis
et al., 2013). Two previous systematic reviews (SRs) on this topic
evaluated bone and soft tissue changes (Tan et al., 2012; Van der
Weijden et al., 2009). Studies included in these SRs were markedly
heterogeneous, and no attempt to explore the role of different
variables on the outcomes was made. The aim of this SR was to
answer the following focused question: What are the dimensional
changes in the alveolar ridge that result from unassisted socket
healing in adult human subjects in function of relevant local, sys-
temic and surgical factors?
2   |  M ATE R I A L S A N D M E TH O DS
The protocol of this review was previously registered in the
International Prospective Register of Systematic Reviews
(PROSPERO) with the identification code CRD42020178857.
This review fully adhered to the guidelines of the Preferred
Reporting Items of Systematic Reviews and Meta-Analyses
(Moher, Liberati, Tetzlaff, Altman, & Group) statement (Moher
et al., 2009).
2.1  |  PICO Question
“What are the dimensional changes of the alveolar ridge that result
from unassisted socket healing in adult human subjects in function
of relevant local, systemic and surgical factors?”
Population
Adult human subjects (>18 years of age) requiring single tooth
extraction, except mandibular incisors and third molars.
Intervention
The intervention of interest was standard-of-care tooth ex-
traction with or without socket curettage, irrigation and suturing as
required.
Comparison
No comparison groups.
Outcomes
Clinical Relevance
Scientific rationale: There is a lack of evidence from previous
systematic reviews (SRs) regarding post-extraction dimen-
sional changes in the alveolar ridge after unassisted socket
healing in function of local, systemic and surgical factors.
Principal findings: Horizontal and vertical alveolar ridge re-
duction was consistently reported in all articles included
in this SR. These dimensional alterations are more accen-
tuated on the coronal aspect of the ridge and can be pri-
marily attributed to bone resorption. Increased horizontal
ridge reduction was observed in molar sites compared with
non-molar sites. Facial bone thickness upon extraction was
strongly associated with the extent and magnitude of al-
veolar bone resorption, specifically in non-molar sites.
Practical implications: Alveolar bone resorption is a physiologic
phenomenon that occurs as a consequence of tooth extrac-
tion. Dimensional changes seem to be larger in molar sites,
particularly in the horizontal dimension. However, this was not
directly correlated with the need for ancillary bone grafting
prior to or at the time of implant placement. This information
should be taken into consideration when making clinical deci-
sions pertaining to the management of fresh extraction sites.
A Dimensional changes in the alveolar ridge:
A.1. Bone linear measurements [horizontal, mid-facial, mid-lingual]
in mm assessed clinically upon surgical re-entry or radio-
graphically (primary outcome of interest).
A.2. Bone volumetric measurements in mm3 assessed radiographi-
cally using DICOM files.
A.3. Soft or hard tissue linear [horizontal, mid-facial, mid-lingual] or
volumetric assessments, in mm and mm3, respectively, assessed
digitally using stereolithography (STL) files.
A Incidence and type of complications during the healing period.
B Feasibility of implant placement / need for ancillary site de-
velopment procedures prior to or simultaneous with implant
placement.
C Patient-reported outcome measures (PROMs): discomfort, per-
ceived benefit and quality-of-life changes.
In addition, the effect of several factors on the outcomes of inter-
est was explored. These factors were divided into four categories: (1)
patient-related (i.e. smoking habits, diabetes, history of periodontitis),
(2) local anatomical (i.e. non-molar or molar site, socket integrity), (3)
phenotypic (keratinized tissue width, soft tissue and bone plate thick-
ness, supracrestal tissue attachment dimension) and (4) surgical-re-
lated (i.e. flap elevation, primary or secondary intention healing).
COUSO-QUEIRUGA ET AL.
2.2  |  Criteria for study inclusion
Proper RCTs, non-RCTs and prospective case series published in
English language that reported the outcomes of unassisted socket
healing after tooth extraction were included.
Clinical scenarios included in this review were (1) intact or
well-preserved extraction sites and (2) partially damaged sites
presenting a minimum of 50% of alveolar bone height loss on any
wall. Studies involving any additional intervention that may have
influenced the outcomes of interest (i.e. collagen plug or autolo-
gous blood-derived product placement in the socket or delivery
of an immediate removable mucosa-supported prosthesis) were
excluded. For inclusion, studies must have recruited adult human
subjects (>18 years of age) requiring single tooth extraction, except
mandibular incisors and third molars. A minimum post-operative fol-
low-up period of 2 months (≥8 weeks) and a maximum of 12 months
(≤52 weeks) were required for inclusion. No minimum number of pa-
tients per study was necessary for inclusion. Finally, studies must
have reported at least one of the outcomes of interest aforemen-
tioned to be eligible.
2.3  |  Search methods
Three electronic databases were searched, namely National Library
of Medicine (MEDLINE–PubMed), Cochrane Central Register of
Controlled Trials (CENTRAL) and EMBASE using a specific MEDLINE
strategy. The last electronic search was conducted on 15 August
2020. Additionally, a thorough hand search was performed (see
Appendix 1 for more information).
2.4  |  Article selection
Two reviewers (E.C.Q. and M.T.) independently read the title and
abstract of the entries obtained from the literature searches and
made a preliminary selection. Then, both reviewers read individually
through the full-text versions of the potentially eligible studies. Final
article selection based on the aforementioned eligibility criteria was
performed. Both reviewers had an open discussion when disagree-
ment regarding the final selection of an article occurred. If no agree-
ment was achieved, another co-author (S.S.) made the final decision.
2.5  |  Data extraction
Data extraction was done separately by two of the authors (E.C.Q
and M.T.). The accuracy of the data was verified independently by a
third author (S.S.). In addition to the outcomes of interest and fac-
tors previously outlined, additional data extracted included year of
publication and first author, study design, initial number of partici-
pants and distribution by groups, number of drop-outs, age and gen-
der distribution, smoking habits, diabetes, history of periodontitis,
|
      129
reason(s) for extraction, socket anatomy (i.e. non-molar or molar
site), supracrestal tissue attachment (previously termed biologic
width), keratinized tissue width, facial and lingual soft tissue thick-
ness, facial and lingual bone plate thickness, flap elevation, primary
closure and total healing period. Any missing data that could contrib-
ute to the conduction of this review were requested from the cor-
responding authors of the original articles via email communication.
If no response was received, the requested data set was excluded
from the final analysis.
2.6  |  Risk-of-bias assessment
The risk-of-bias analyses of each RCT included in the final selection
were independently performed by two authors (M.T. and S.S.) using
the Cochrane Collaboration's tool for assessing risk of bias in rand-
omized clinical trials (Higgins et al., 2019). RCTs were categorized
as being at low, some concerns or high risk of bias. Non-RCTs were
assessed using the ROBINS-I tool (Sterne et al., 2016). Each non-RCT
was categorized as having no information or being at low, moderate,
serious or critical risk of bias (see Appendix 1 for more information).
Disagreement between reviewers was resolved by open discussion.
In case that no agreement could be achieved, the final decision was
made by another co-author (E.C.Q.).
2.7  |  Data synthesis
Data were organized into evidence tables, and a descriptive sum-
mary was performed to determine the quantity of data and study
variations (i.e. study subjects, extraction site features and results).
Following article selection, Cohen's kappa coefficient (k) was per-
formed to assess inter-examiner agreement. Continuous data were
pooled into random-effects meta-analyses and expressed as initial
and final averages to calculate mean differences (MD) with their as-
sociated 95% confidence intervals (CI). The analyses were performed
using the generic inverse variance statistical method where the MD
and standard error (SE) are entered for all studies (Stedman et al.,
2011). Statistical heterogeneity was assessed by calculation of the
Q statistic. The significance of discrepancies in the estimates of the
treatment effects from the different trials was assessed by means of
Cochrane's test for heterogeneity and the I2 statistic. Analyses were
performed using RevMan software (Review Manager 5, version 5.3;
Nordic Cochrane Centre).
3  |  R E S U LT S
3.1  |  Search results
The initial database search yielded a total of 11,075 entries, of
which 5180 were found in PubMed, 1960 in EMBASE and 3935 in
CENTRAL. Following duplicate removal, 7356 entries remained.
 |
130      COUSO-QUEIRUGA ET AL.
After title and abstract screening, a total of 106 articles were se-
lected for full-text review. Four additional articles were identi-
fied through hand searching. Seventy-eight of these articles were
excluded after full-text review, the reasons for which are sum-
marized in Table S1 . Thus, the final selection was comprised of
28 articles, of which 25 were RCTs (Aimetti et al., 2009; Araujo
et al., 2015; Avila-Ortiz et al., 2020 ; Barone et al., 2008 , 2017;
Canellas et al., 2020 ; Cha et al., 2019; Clementini et al., 2019;
Festa et al., 2013; Fiorellini et al., 2005; Hauser et al., 2013;
Iasella et al., 2003; Jung et al., 2013; Karaca et al., 2015; Lim
et al., 2019; Machtei et al., 2019; Pang et al., 2016; Pelegrine
et al., 2010 ; Qabbani et al., 2017; Rasperini et al., 2010 ; Sisti et al.,
2012; Spinato et al., 2014; Sun et al., 2019; Thalmair et al., 2013;
Thoma et al., 2020 ) and three were non-RCTs (Jiang et al., 2017;
Sbordone et al., 2017; Zhao et al., 2018). Kappa scores for inter-
examiner agreement for title and abstract review as well as full-
text review were 0.91 and 0.82, respectively. The article selection
process is depicted in Figure 1 .
F I G U R E 1  Search and article selection process
3.2  |  Characteristics of the included studies
The general characteristics of the 28 selected studies including
study design, population, setting, extraction site features and fol-
low-up (healing) time are displayed in Table S2.
3.3  |  Risk of bias in selected studies
Fourteen RCTs were categorized as presenting low risk (Araujo
et al., 2015; Avila-Ortiz et al., 2020; Barone et al., 2008, 2017;
Canellas et al., 2020; Cha et al., 2019; Clementini et al., 2019; Iasella
et al., 2003; Jung et al., 2013; Lim et al., 2019; Machtei et al., 2019;
Rasperini et al., 2010; Sisti et al., 2012; Sun et al., 2019), two RCTs as
some concerns (Hauser et al., 2013; Pang et al., 2016) and nine RCTs
as high risk of bias (Aimetti et al., 2009; Festa et al., 2013; Fiorellini
et al., 2005; Karaca et al., 2015; Pelegrine et al., 2010; Qabbani et al.,
2017; Spinato et al., 2014; Thalmair et al., 2013; Thoma et al., 2020).
COUSO-QUEIRUGA ET AL. |
      131

Two non-RCTs were categorized as low risk (Sbordone et al., 2017;

Zhao et al., 2018), and the remaining one was categorized as serious
risk (Jiang et al., 2017) as displayed in Figures 2 and 3.

3.4  |  Qualitative assessment of outcomes

The extracted data pertaining to the clinical and radiographic out-

comes of interest are displayed in Table 1, while data on STL analy-
ses and patient-reported outcomes are shown in Table S3.

3.4.1  |  Dimensional outcomes

Clinical horizontal bone changes

Differences in horizontal (facio-lingual) bone changes between
baseline and final follow-up assessed by direct clinical measure-
ments were reported in ten studies. Nine studies included only non-
molar teeth (Aimetti et al., 2009; Barone et al., 2008, 2017; Festa
et al., 2013; Hauser et al., 2013; Iasella et al., 2003; Machtei et al.,
2019; Pelegrine et al., 2010; Spinato et al., 2014), whereas one study
included a mix of non-molars and molar teeth, showing higher net
amounts of horizontal alveolar ridge resorption in non-molars vs
molars (−3.60 ± 0.72 vs −3.13 ± 0.35 mm) (Barone et al., 2017). In
F I G U R E 3  Risk-of-bias assessment of non-RCTs
six studies, a stent or template was used (Barone et al., 2008; Festa
et al., 2013; Hauser et al., 2013; Machtei et al., 2019; Pelegrine et al.,
2010; Spinato et al., 2014). In the trial by Spinato et al. (2014), pa-
tients were divided into subgroups according to the thickness of in nine studies, with all reporting differences in mid-facial vertical
the facial bone plate in non-molar maxillary sites. Sites presenting bone changes (Aimetti et al., 2009; Barone et al., 2008 , 2017; Festa
a thick facial bone plate (>1 mm) showed less horizontal resorption et al., 2013; Iasella et al., 2003; Machtei et al., 2019; Pelegrine
than those with a thin plate (≤1 mm) (1.17 ± 0.41 vs 2.67 ± 0.52 mm). et al., 2010 ; Rasperini et al., 2010 ; Spinato et al., 2014). Six trials
reported differences in mid-lingual bone changes (Aimetti et al.,
Clinical vertical bone changes 2009; Barone et al., 2008 , 2017; Festa et al., 2013; Iasella et al.,
Differences in vertical bone changes between baseline and final 2003; Spinato et al., 2014). Two studies did not utilize a stent to
follow-up assessed by direct clinical measurements were reported assess the changes (Pelegrine et al., 2010 ; Spinato et al., 2014). In

F I G U R E 2  Risk-of-bias assessment of RCTs

TA B L E 1  Quantitative data of included studies pertaining to the clinical and radiographic outcomes of interest

132     
Clinical outcomes Radiographic outcomes (CBCT)

|
Vertical mid- Feasibility of Vertical mid-
Publication(s) Vertical mid-facial lingual bone implant placement Vertical mid- lingual change Volumetric
Author and Horizontal bone change in bone change in mm change in mm with no additional Incidence and type Horizontal change in mm facial change in in mm (mean change in mm3
Year (s) mm (mean ±SD) (mean ±SD) (mean ±SD) bone grafting of complications (mean ±SD) mm (mean ±SD) ±SD) (mean ±SD)
Iasella et al. Baseline: 9.1 ± 1.0 −0.9 ± 1.6 (only −0.4 ± 1.0 (only N/R N/R N/R N/R N/R N/R
(2003) 4 to 6 months: 6.4 ± 2.2 changes changes
reported) reported)
Fiorellini et al. N/R N/R N/R 9 of 20 sites (45%) Oral oedema (75%) +0.57 ± 2.56 (only −1.17 ± 1.23 N/R N/R
(2005) Mouth pain (68%) changes reported) (only changes
Oral erythema (46%) reported)
There were a greater
number of events
of oral oedema
and erythema in
the test groups
compared with
the control,
but details not
specified.
Barone et al. Baseline: 10.8 ± 0.8 −3.6 ± 1.5 (only −3.0 ± 1.6 (only N/R None N/R N/R N/R N/R
(2008) 7–9 months: 8.1 ± 1.4 changes changes
reported) reported)
Aimetti et al. Baseline: 10 ± 0.7 Baseline: 9.9 ± 2 Baseline: N/R None N/R N/R N/R N/R
(2009) 3 months: 6.8 ± 1.3 3 months: 8.8 ± 0.9
11.1 ± 2.2 3 months:
9.7 ± 1.7
Pelegrine Baseline: 7.38 ± 0.49 Baseline: N/R N/R None N/R N/R N/R N/R
et al. 6 months: 4.92 ± 0.86 2.46 ± 0.4
(2010) 6 months:
1.29 ± 0.4

COUSO-QUEIRUGA ET AL.
(Continues)
TA B L E 1  Continued

Clinical outcomes Radiographic outcomes (CBCT)

Vertical mid- Feasibility of Vertical mid-
Publication(s) Vertical mid-facial lingual bone implant placement Vertical mid- lingual change Volumetric
Author and Horizontal bone change in bone change in mm change in mm with no additional Incidence and type Horizontal change in mm facial change in in mm (mean change in mm3
Year (s) mm (mean ±SD) (mean ±SD) (mean ±SD) bone grafting of complications (mean ±SD) mm (mean ±SD) ±SD) (mean ±SD)
Rasperini N/R No significant N/R No significant N/R N/R N/R N/R N/R
et al. defects/ defects: 2 of 3
(2010) all walls (66%)
remaining: Partially damaged
Initial: 8.3 ± 3.2 sites: 3 of 5
Final: missing (60%)
Changes:
−5.7 ± 4.2
Partially damaged
sites:
Initial: 16.4 ± 4
Final: missing
Changes: 0.6 ± 3.9
(no reported
final data)
Sisti et al. N/R N/R N/R 0 of 20 sites None N/R N/R N/R N/R
(2012) (100%)
Festa et al. Baseline: 9.9 ± 1 −3.1 ± 1.3 (only −2.4 ± 1.6 (only N/R None N/R N/R N/R N/R
(2013) 6 months: 6.2 ± 1.3 changes changes
reported) reported)
Hauser et al. −0.43 (perpendicular to the N/R N/R 7 of 7 (100%) None N/R N/R N/R N/R
(2013) tangent of the dental
arch at the mid-point
of the extraction site
approximately 4 mm
under the level of the
gingiva of the adjacent
teeth and corresponded
to the distance between
the most prominent
points buccally and
orally) (only changes
reported)
Jung et al. N/R N/R N/R N/R None At 1 mm: −3.3 ± 2.0 −0.5 ± 0.9 (only −0.6 ± 0.6 (only N/R
(2013) At 3 mm: −1.7 ± 0.8 changes changes
At 5 mm: −0.8 ± 1.2 (only reported) reported)
changes reported)

      133
|
(Continues)
 134     
|
TA B L E 1  Continued

Clinical outcomes Radiographic outcomes (CBCT)

Vertical mid- Feasibility of Vertical mid-
Publication(s) Vertical mid-facial lingual bone implant placement Vertical mid- lingual change Volumetric
Author and Horizontal bone change in bone change in mm change in mm with no additional Incidence and type Horizontal change in mm facial change in in mm (mean change in mm3
Year (s) mm (mean ±SD) (mean ±SD) (mean ±SD) bone grafting of complications (mean ±SD) mm (mean ±SD) ±SD) (mean ±SD)
Thalmair et al. N/R N/R N/R N/R None N/R N/R N/R N/R
(2013)
Spinato et al. Thin: −2.67 ± 0.52 Thin: −1.17 ± 0.4 Thin: −1.0 ± 0.63 N/R None N/R N/R N/R N/R
(2014) Thick: −1.17 ± 0.41 (only Thick: −0.50 ± 0.55 Thick:
changes reported) (only changes −0.5 ± 0.55
reported) (only
changes
reported)
Araújo et al. N/R N/R N/R N/R None N/R Baseline: Baseline: N/R
(2015) 9.4 ± 1.6 9.3 ± 2.6
4 months: 4 months:
5.8 ± 2.2 7.9 ± 2.4
Karaca et al. N/R N/R N/R N/R None N/R Baseline: 7.26 Baseline: 6.96 N/R
(2015) 3 months: 5.98 3 months: 5.84
(median (median
values) values)
Pang et al. N/R N/R N/R N/R N/R No significant defects: N/R N/R N/R
(2016) −3.26 ± 0.44
Partially damaged sites:
−3.82 ± 0.33
Sbordone N/R N/R N/R N/R None N/R N/R N/R N/R
et al.
(2017 )
Jiang et al. N/R N/R N/R 0/12 (100%) None Baseline: N/R N/R N/R
(2017 ) 6.97 ± 0.91
4 months:
3.85 ± 1.14

COUSO-QUEIRUGA ET AL.
(Continues)
TA B L E 1  Continued

COUSO-QUEIRUGA ET AL.
Clinical outcomes Radiographic outcomes (CBCT)
Vertical mid- Feasibility of Vertical mid-
Publication(s) Vertical mid-facial lingual bone implant placement Vertical mid- lingual change Volumetric
Author and Horizontal bone change in bone change in mm change in mm with no additional Incidence and type Horizontal change in mm facial change in in mm (mean change in mm3
Year (s) mm (mean ±SD) (mean ±SD) (mean ±SD) bone grafting of complications (mean ±SD) mm (mean ±SD) ±SD) (mean ±SD)
Qabbani et al. N/R N/R N/R N/R None Baseline: N/R N/R N/R
(2017 ) At 0 mm: 6.74 ± 1.11
At 3 mm apical:
8.22 ± 1.30
At 5 mm apical:
9.22 ± 1.39
At 7 mm apical:
10.40 ± 1.38
9 months:
At 0 mm: 4.90 ± 1.13
At 3 mm apical:
6.51 ± 0.79
At 5 mm apical:
8.31 ± 1.79
At 7 mm apical:
9.76 ± 2.30
Barone et al. Anterior: −3.60 ± 0.72 Anterior: Anterior: N/R N/R N/R N/R N/R N/R
(2017 ) Posterior: - 3.13 ± 0.35 −2.10 ± 0.66 −2.03 ± 0.72
(only changes reported) Posterior: Posterior:
−2.25 ± 0.46 −2.13 ± 0.84
(only changes (only
reported) changes
reported)
Zhao et al. N/R N/R N/R N/R None N/R Buccal ridge Buccal ridge N/R
(2018) height height
>lingual >lingual
ridge height: ridge height:
−1.18 ± 1.48 - 0.55 ± 1.00
Buccal ridge Buccal ridge
height height
<lingual <lingual
ridge height: ridge height:
- 0.48 ± 3.42 −2.16 ± 1.62
Machtei et al. Baseline: Baseline: 7.69 ± 4.2 N/R N/R N/R N/R N/R N/R N/R
(2019) At 3 mm: 8.31 ± 1.4 4.5 ± 0.4 months:
At 6 mm: 8.30 ± 1.9 9.88 ± 3.6
4.5 ± 0.4 months:
At 3 mm: 5.35 ± 1.2
At 6 mm: 6.50 ± 1.7

      135
|
(Continues)
 136     
|
TA B L E 1  Continued

Clinical outcomes Radiographic outcomes (CBCT)

Vertical mid- Feasibility of Vertical mid-
Publication(s) Vertical mid-facial lingual bone implant placement Vertical mid- lingual change Volumetric
Author and Horizontal bone change in bone change in mm change in mm with no additional Incidence and type Horizontal change in mm facial change in in mm (mean change in mm3
Year (s) mm (mean ±SD) (mean ±SD) (mean ±SD) bone grafting of complications (mean ±SD) mm (mean ±SD) ±SD) (mean ±SD)
Cha et al. N/R N/R N/R 0 of 14 (100%) None Baseline: N/R N/R N/R
(2019) All of them At 2 mm: 7.81 CI (5.79,
needed sinus 9.69)
augmentation At 4 mm: 10.77 CI (8.85,
procedure 12.64)
At 6 mm: 14.09 (12.44,
15.40)
6 months:
At 2 mm: 4.27 CI (2.17,
6.58)
At 4 mm: 8.97 CI (7.05,
11.03)
At 6 mm: 12.74 (11.38,
14.13)
Clementini N/R N/R N/R N/R None At 1 mm: −3.37 ± 1.55 −0.83 ± 1.14 −0.21 ± 0.31 N/R
et al. At 3 mm: −2.41 ± 1.97 (only changes (only
(2019) At 5 mm: −1.88 ± 1.55 reported) changes
(only changes reported) reported)
Sun et al. N/R N/R N/R 4 of 13 (31%) None Non-molar sites: Non-molar sites: Non-molar sites: N/R
(2019) At 1 mm: −3.9 ± 3.2 −1.9 ± 2.4 −0.9 ± 0.8
At 3 mm: −1.8 ± 1.1 Molar sites: Molar sites:
At 5 mm: −1.0 ± 0.9 −3 ± 2.6 −1.3 ± 1.8
Molar sites: (only changes (only
At 1 mm: −6.5 ± 4.2 reported) changes
At 3 mm: −2.9 ± 3.7 reported)
At 5 mm: −1.0 ± 0.6 (only
changes reported)
Lim et al. N/R N/R N/R 5 of 8 (62.5%) None At 1 mm: −4.44 ± 3.71 −1.33 ± 1.11 −1.20 ± 0.96 N/R
(2019) At 3 mm: −2.27 ± 1.15 (only changes (only
At 5 mm: −0.84 ± 0.75 reported) changes

COUSO-QUEIRUGA ET AL.
(only changes reported)
reported)

(Continues)
 COUSO-QUEIRUGA ET AL.
TA B L E 1  Continued

Clinical outcomes Radiographic outcomes (CBCT)

Vertical mid- Feasibility of Vertical mid-
Publication(s) Vertical mid-facial lingual bone implant placement Vertical mid- lingual change Volumetric
Author and Horizontal bone change in bone change in mm change in mm with no additional Incidence and type Horizontal change in mm facial change in in mm (mean change in mm3
Year (s) mm (mean ±SD) (mean ±SD) (mean ±SD) bone grafting of complications (mean ±SD) mm (mean ±SD) ±SD) (mean ±SD)
Thoma et al. N/R N/R N/R 1 of 11 (9.1%) None N/R N/R N/R N/R
(2020) Thin buccal bone
<1.5 mm
(n = 1);
Dehiscence
defect type
after implant
placement
(n = 5);
intra-bony
defect type
after implant
placement 1
(n = 1)
Canellas et al. N/R N/R N/R N/R One implant had At 1 mm: −2.27 ± 1.21 −1.39 ± 1.28 −1.24 ± 1.15 −44.87 ± 200.20
(2020) to be removed At 3 mm: −1.67 ± 1.10 (only changes (only changes
2 months after At 5 mm: −1.08 ± 1.04 reported) reported)
placement (only changes
due to lack of reported)
osseointegration.
(not specified
which group)
Avila et al. N/R N/R N/R 14 of 27 (51.9%) None −1.67 ± 1.17 −1.7 ± 1.60 −0.91 ± 0.63 −154.51 ± 69.35
(2020) (CI: −2.10 to −1.26)

      137
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138      COUSO-QUEIRUGA ET AL.
one of them, vertical changes were assessed using titanium screws
as reference points, which were inserted into the facial and lingual
bone plate (Pelegrine et al., 2010). In the other trial, a periodontal
probe using the CEJs of the adjacent teeth as a horizontal refer-
ence line was utilized (Spinato et al., 2014). For all vertical bone
changes, non-molar sites consistently rendered more mid-facial
than mid-lingual bone resorption. Interestingly, the trial by Spinato
et al. (2014) showed exactly the same amount of mid-facial and
mid-lingual resorption in non-molar maxillary sites when a thick fa-
cial bone plate (>1 mm) was present (−0.5 ± 0.55 vs −0.5 ± 0.55 mm,
respectively). In one study (Rasperini et al., 2010), more bone re-
modelling was observed when the molar socket was intact vs a
molar socket that was severely damaged. Barone and co-workers
(Barone et al., 2017 ), however, reported similar mid-facial and mid-
lingual bone changes in the posterior and anterior regions (mid-
facial: −2.25 ± 0.46 vs −2.10 ± 0.66 mm / mid-lingual: −2.13 ± 0.84,
−2.03 ± 0.72 mm, respectively), although the distribution of socket
integrity was not reported.
Radiographic horizontal bone changes
Differences in horizontal bone changes between baseline and final
follow-up assessed in CBCT scan images were reported in eleven
studies (Avila-Ortiz et al., 2020; Canellas et al., 2020; Cha et al.,
2019; Clementini et al., 2019; Fiorellini et al., 2005; Jiang et al., 2017;
Jung et al., 2013; Lim et al., 2019; Pang et al., 2016; Qabbani et al.,
2017; Sun et al., 2019). Seven studies assessed horizontal changes
at different levels (i.e. 1, 3 and 5 mm apical to the crestal bone)
(Canellas et al., 2020; Cha et al., 2019; Clementini et al., 2019; Jung
et al., 2013; Lim et al., 2019; Qabbani et al., 2017; Sun et al., 2019).
More horizontal resorption in molar sites compared with non-molar
sites was consistently reported.
Radiographic vertical bone changes
Differences in vertical bone changes between baseline and final
follow-up assessed in CBCT scan images were reported in ten
studies (Araujo et al., 2015; Avila-Ortiz et al., 2020 ; Canellas et al.,
2020 ; Clementini et al., 2019; Fiorellini et al., 2005; Jung et al.,
2013; Karaca et al., 2015; Lim et al., 2019; Sun et al., 2019; Zhao
et al., 2018). All studies reported changes at mid-facial and mid-lin-
gual sites, except for one (Fiorellini et al., 2005) that only reported
mid-facial vertical bone changes. Overall, more bone resorption at
mid-facial sites compared with mid-lingual sites was reported in the
selected studies. Non-molar sites exhibited less vertical bone loss
than molar sites.
Volumetric bone changes assessed in DICOM files
Differences in bone volumetric changes between baseline and final
follow-up assessed by CBCT scan images were reported in two stud-
ies including non-molar teeth (Avila-Ortiz et al., 2020; Canellas et al.,
2020). The trial by Canellas et al. revealed less volumetric reduction
but a higher standard deviation than the study by Avila-Ortiz et al.
(−44.87 ± 200.20 vs −154.51 ± 69.35 mm3).
Linear and volumetric changes assessed in STL files
Linear changes in alveolar ridge soft tissue contour assessed in STL
files were reported in two studies (Thalmair et al., 2013; Thoma et al.,
2020). Average ridge contour reduction was higher in the study con-
ducted by Thalmair et al. compared with the one by Thoma and col-
laborators (−2.29 ± 1.1 vs −1.8 ± 0.8 mm). Thalmair and co-workers
assessed the measurements at the most coronal contour line of the
alveolar ridge. Meanwhile, Thoma et al. assessed horizontal linear
changes at 3 and 5 mm apical from the mucosal margin. Only three
studies assessed soft tissue volumetric changes between baseline
and final follow-up (Avila-Ortiz et al., 2020; Sbordone et al., 2017;
Thalmair et al., 2013). Significant value discrepancies were observed
in non-molar teeth (initial: 990 ± 0.40 mm3 and final: 540 ± 0.20 mm3)
in the study by Sbordone et al. compared with the study by Thalmair
and collaborators (−41.41 ± 15.96 mm3), which reported lower mean
values than Avila-Ortiz and colleagues (−107.27 ± 48.11 mm3). Data
on bone tissue volumetric changes assessed by stereolithography
were not reported in any of the selected studies.
3.4.2  |  Complications
Only one study reported the occurrence of complications (Fiorellini
et al., 2005), twenty-two studies reported uneventful healing
(Aimetti et al., 2009; Araujo et al., 2015; Avila-Ortiz et al., 2020;
Barone et al., 2008; Canellas et al., 2020; Cha et al., 2019; Clementini
et al., 2019; Festa et al., 2013; Hauser et al., 2013; Jiang et al., 2017;
Jung et al., 2013; Karaca et al., 2015; Lim et al., 2019; Pelegrine
et al., 2010; Qabbani et al., 2017; Sbordone et al., 2017; Sisti et al.,
2012; Spinato et al., 2014; Sun et al., 2019; Thalmair et al., 2013;
Thoma et al., 2020; Zhao et al., 2018) and five studies did not specify
whether complications occurred (Barone et al., 2017; Iasella et al.,
2003; Machtei et al., 2019; Pang et al., 2016; Rasperini et al., 2010).
3.4.3  |  Feasibility of implant placement
Ten studies reported data on the feasibility of implant placement
with no additional bone grafting procedures at the same time or
prior to implant placement (Avila-Ortiz et al., 2020 ; Cha et al.,
2019; Fiorellini et al., 2005; Hauser et al., 2013; Jiang et al., 2017;
Lim et al., 2019; Rasperini et al., 2010 ; Sisti et al., 2012; Sun et al.,
2019; Thoma et al., 2020). Only two of the selected trials reported
the criteria applied to make this determination (Avila-Ortiz et al.,
2020 ; Thoma et al., 2020). Six of them reported data exclusively
on non-molar sites (Avila-Ortiz et al., 2020 ; Fiorellini et al., 2005;
Hauser et al., 2013; Jiang et al., 2017; Sisti et al., 2012; Thoma
et al., 2020), three studies on molar sites (Cha et al., 2019; Lim
et al., 2019; Rasperini et al., 2010) and one study on non-molar and
molar sites (Sun et al., 2019). Overall, these studies showed that
69.7% of non-molar and 45.9% of molar sites required additional
bone augmentation.
COUSO-QUEIRUGA ET AL.
F I G U R E 4  Visual representation of the main findings derived from the quantitative analyses
3.4.4  |  Patient-reported outcomes
Only two studies reported PROMS (Avila-Ortiz et al., 2020; Machtei
et al., 2019). The study by Machtei used a VAS scale with a range be-
tween 0 and 5 to assess the post-operative pain level at the 2 weeks
post-op visit. This trial reported higher mean values than the study
by Avila-Ortiz and co-workers in which discomfort was analysed
at each post-operative visit using a VAS scale between 0 and 100,
showing a progressive decrease over time. This was the only study
reporting the perceived benefit of therapy after completion of treat-
ment (95.52 ± 9.56 out of 100).
3.5  |  Quantitative analyses (Pooled estimates)
Meta-analyses were only performed if at least two studies with
similar extraction site features reported the same outcome of inter-
est. As shown in Figure 1, twenty studies met this criterion (Aimetti
et al., 2009; Araujo et al., 2015; Avila-Ortiz et al., 2020; Barone et al.,
2008, 2017; Canellas et al., 2020; Cha et al., 2019; Clementini et al.,
2019; Festa et al., 2013; Iasella et al., 2003; Jiang et al., 2017; Jung
et al., 2013; Lim et al., 2019; Machtei et al., 2019; Pang et al., 2016;
Pelegrine et al., 2010; Qabbani et al., 2017; Spinato et al., 2014; Sun
et al., 2019; Zhao et al., 2018). Available data allowed for grouping by
arch (i.e. maxillary, mandibular or both) and location (i.e. non-molar
or molar sites). A visual summary of the main findings is displayed in
Figure 4.
3.5.1  |  Clinical horizontal bone changes in non-
molar sites
Evidence of horizontal bone reduction from baseline to final follow-
up in non-molar sites was found ( p < 0.00001, MD: 2.73 mm, 95%
CI: 2.36–3.11, I2 = 94.0%) (Figure S1). Slightly less horizontal bone
|
      139
reduction was observed when only maxillary sites were analysed
( p < 0.00001, MD: 2.38 mm, 95% CI: 1.46–3.29, I2 = 97.0%). Less
horizontal bone resorption in non-molar maxillary sites was ob-
served when a thick facial bone plate was present ( p < 0.00001, MD:
1.17 mm, 95% CI: 0.84–1.50) compared to sites with thin facial bone
( p < 0.00001, MD: 2.67 mm, 95% CI: 2.26–3.08).
3.5.2  |  Clinical mid-facial vertical bone changes
in non-molar sites
Evidence of mid-facial vertical bone reduction from baseline to
final follow-up in non-molar sites was found ( p < 0.00001, MD:
1.71 mm, 95% CI: 1.30–2.12, I2 = 94.0%) (Figure S2). The magni-
tude of this dimensional change was lower when only maxillary
sites were analysed ( p < 0.00001, MD: 1.09 mm, 95% CI: 0.89–
1.29, I2 = 69.0%). Less mid-facial bone height loss was observed
in non-molar maxillary sites presenting a thick facial bone plate
( p < 0.00001, MD: 0.50 mm, 95% CI: 0.07–0.93) compared to sites
with a thin facial bone plate ( p < 0.00001, MD: 1.17 mm, 95% CI:
0.86–1.48).
3.5.3  |  Clinical mid-lingual vertical bone changes
in non-molar sites
Evidence of mid-lingual vertical bone reduction from baseline to
final follow-up in non-molar sites was found ( p < 0.00001, MD:
1.44 mm, 95% CI: 0.78–2.10, I2 = 91.0%) (Figure S3). When only
maxillary sites were analysed, less bone reduction was observed
( p < 0.00001, MD: 0.79 mm, 95% CI: 0.50–1.08, I2 = 27.0%).
Maxillary sites with thick facial bone showed less mid-lingual re-
sorption ( p = 0.02, MD: 0.50 mm, 95% CI: 0.07–0.93) compared
with those exhibiting a thin facial bone plate ( p = 0.0001, MD:
1.00 mm, 95% CI: 0.49–1.51).
 |
140      COUSO-QUEIRUGA ET AL.
3.5.4  |  Radiographic horizontal bone changes
in non-molar and molar sites
Evidence of horizontal bone reduction from baseline to final follow-
up was found in non-molar sites ( p < 0.00001, MD: 2.54 mm, 95% CI:
1.97–3.11, I2 = 91.0%) and molar sites ( p < 0.00001, MD: 3.61 mm,
2
95% CI: 3.24–3.98, I = 80.0%) (Figure S4). The magnitude of hori-
zontal bone loss was higher in molar sites vs non-molar sites (3.61 vs
2.54 mm, respectively).
3.5.5  |  Radiographic mid-facial vertical bone
changes in non-molar and molar sites
Evidence of mid-facial vertical bone reduction from baseline to final
follow-up was found in non-molar sites ( p < 0.00001, MD: 1.65 mm,
95% CI: 0.42–2.88, I2 = 96.0%) and molar sites ( p < 0.0001, MD:
1.46 mm, 95% CI: 0.73–2.20, I2 = 30.0%) (Figure S5). The magnitude
of mid-facial vertical bone resorption was slightly higher in non-mo-
lar sites (1.65 vs 1.46 mm).
3.5.6  |  Radiographic mid-lingual vertical bone
changes in non-molar and molar sites
Evidence of mid-lingual vertical bone reduction from baseline to
final follow-up was found in non-molar sites ( p < 0.00001, MD:
0.87 mm, 95% CI: 0.36–1.38, I2 = 97.0%) and molar sites ( p < 0.0001,
MD: 1.20 mm, 95% CI: 0.56–1.83, I2 = 53%) (Figure S6). Less mid-
lingual vertical bone loss was observed in non-molar vs molar sites
(0.79 vs 1.20 mm).
4   |  D I S CU S S I O N
4.1  |  Summary of main findings
Data collected in this SR indicate that the naturally occurring resorp-
tive process that follows tooth extraction results into significant
changes to the alveolar ridge dimensions, irrespective of tooth type.
Molar sites generally exhibit more resorption on the coronal aspect
of the alveolar ridge for all dimensions analysed, except for vertical
mid-facial changes compared with non-molar sites. Additionally, a
combined estimation of the data from studies reporting the need
for bone augmentation to facilitate implant placement revealed that
that 69.7% of non-molar sites and 45.9% of molar sites required
additional bone augmentation. Although complications were only
described in one study (Fiorellini et al., 2005), most of the studies
(n = 22) reported uneventful healing after tooth extraction (Aimetti
et al., 2009; Araujo et al., 2015; Avila-Ortiz et al., 2020; Barone
et al., 2008; Canellas et al., 2020; Cha et al., 2019; Clementini et al.,
2019; Festa et al., 2013; Hauser et al., 2013; Jiang et al., 2017; Jung
et al., 2013; Karaca et al., 2015; Lim et al., 2019; Pelegrine et al.,
2010; Qabbani et al., 2017; Sbordone et al., 2017; Sisti et al., 2012;
Spinato et al., 2014; Sun et al., 2019; Thalmair et al., 2013; Thoma
et al., 2020; Zhao et al., 2018). With respect to pooled estimates
(i.e., meta-analyses), these revealed that the magnitude of post-ex-
traction horizontal changes in molar sites (assessed radiographically)
was substantially higher compared with non-molar sites (assessed
clinically or radiographically), except for vertical mid-facial changes,
as shown in Figure 4. Data regarding facial bone thickness indicated
that it can be used as a predictor of the extent of alveolar bone re-
sorption in non-molar sites, as shown in Figures S1, S2 and S3.
4.2  |  Quality of evidence
The overall quality of evidence of the included studies was average
to low. Only five of the included RCTs met all criteria of the Cochrane
Collaboration's tool for assessing risk of bias (Avila-Ortiz et al., 2020;
Barone et al., 2017; Canellas et al., 2020; Clementini et al., 2019;
Sisti et al., 2012). Sixteen studies were categorized as presenting low
risk, fourteen of which were RCTs (Araujo et al., 2015; Avila-Ortiz
et al., 2020; Barone et al., 2008, 2017; Canellas et al., 2020; Cha
et al., 2019; Clementini et al., 2019; Iasella et al., 2003; Jung et al.,
2013; Lim et al., 2019; Machtei et al., 2019; Rasperini et al., 2010;
Sisti et al., 2012; Sun et al., 2019) and two were non-RCTs (Sbordone
et al., 2017; Zhao et al., 2018). Two RCTs were categorized as pre-
senting some concerns (Hauser et al., 2013; Pang et al., 2016), nine
RCTs were categorized as presenting high risk (Aimetti et al., 2009;
Festa et al., 2013; Fiorellini et al., 2005; Karaca et al., 2015; Pelegrine
et al., 2010; Qabbani et al., 2017; Spinato et al., 2014; Thalmair et al.,
2013; Thoma et al., 2020) and one non-RCT was categorized as pre-
senting serious risk (Jiang et al., 2017). Hence, the findings from this
SR should be interpreted with caution.
4.3  |  Potential biases in the review process
In spite of having adhered to high methodological standards, this
review is not exempt of limitations. Aside from facial bone thick-
ness, the effect of local, systemic and surgical factors could not
be assessed as part of the quantitative analyses. This was mainly
due to discrepancies between studies or missing data. For exam-
ple, local factors, such as whether socket integrity influences the
alveolar ridge dimensions, could not be assessed due to the wide
methodological heterogeneity in the selected trials and the lack
of detail in the available data. Baseline KTW was only reported
in four studies (Avila-Ortiz et al., 2020 ; Clementini et al., 2019;
Lim et al., 2019; Zhao et al., 2018). Soft tissue thickness was only
reported in two trials (Avila-Ortiz et al., 2020 ; Clementini et al.,
2019). Data regarding history of periodontitis were only reported
in one study (Zhao et al., 2018). Supracrestal tissue attachment
dimensions were not reported in any of the selected articles.
Systemic factors such as smoking and diabetes could not be as-
sessed due to the small sample size, methodological discrepancies,
COUSO-QUEIRUGA ET AL.
lack of detailed information and vague eligibility criteria in the in-
cluded studies. Finally, although reported in several studies, the
effect of surgical variables (flap elevation and primary vs second-
ary intention healing) on dimensional changes could not be quan-
titatively analysed since they were not consistently reported in
the trials that provided comparable data on the primary outcomes
of interest (i.e. linear horizontal, mid-facial and mid-lingual ridge
reduction). Likewise, STL file analyses were only reported in five
studies. Linear soft tissue contour changes were evaluated in two
studies (Thalmair et al., 2013; Thoma et al., 2020), while volu-
metric soft tissue contour changes were assessed in three stud-
ies (Avila-Ortiz et al., 2020 ; Sbordone et al., 2017; Thalmair et al.,
2013). Radiographic bone volume assessments were reported
in two studies (Avila-Ortiz et al., 2020 ; Canellas et al., 2020).
PROMs were reported in two studies (Avila-Ortiz et al., 2020 ;
Machtei et al., 2019). In the light of the high degree of methodo-
logical heterogeneity across studies, the aforementioned second-
ary outcomes could not be further evaluated in a pooled analysis.
Finally, data from sites that received any further therapy beyond
standard-of-care tooth extraction (e.g. collagen plug, autologous
blood-derived products, bone grafting, socket sealing, immediate
implant placement or delivery of a removable prosthesis) were not
included in this review. Although it may be argued that the effect
of, for example, a rapidly absorbable collagen sponge on dimen-
sional changes is negligible, this was done to homogenize the clini-
cal scenario of interest as much as possible with the purpose of
eliminating the effect of any additional intervention on the healing
sequence and, therefore, the outcomes of interest considered in
this review.
4.4  |  Agreements and disagreements with other
studies or reviews
To the best of the authors’ knowledge, this SR represents the most
comprehensive analysis of the evidence to date regarding the ex-
tent of post-extraction alveolar ridge dimensional changes after un-
assisted socket healing. In general, the results of the quantitative
analyses conducted in this study are not in alignment with those
reported in previous SRs on this topic (Tan et al., 2012; Van der
Weijden et al., 2009). This could be explained by methodological dis-
crepancies, such as eligibility criteria, number and characteristics of
selected articles, detail of data collection and also that previous SRs
pooled non-molar and molar sites and did not differentiate between
clinical and radiographic assessments.
The findings of this SR regarding horizontal ridge reduction in
molar sites are in accordance with those from a classic clinical study
in which a higher per cent of horizontal ridge resorption was ob-
served in maxillary and mandibular molar regions compared with
premolar sites (Schropp et al., 2003).
Findings pertaining to the predictive value of facial bone thick-
ness are in accordance with the observations reported in a case-se-
ries study that involved the extraction of 39 maxillary anterior teeth
|
      141
(Chappuis et al., 2013). In this study, it was observed that thin facial
bone (<1 mm) was associated with more bone resorption than thick
bone (≥ 1 mm). Furthermore, a trial involving 59 patients revealed
that the thicker the facial bone, the less the bone volume loss that
occurs after a 14-week healing period (Avila-Ortiz et al., 2020).
The lower need for bone augmentation prior to or simultaneously
with implant placement in molar sites identified in the present SR
could be explained by the wider horizontal dimension of these sites
which, in spite of undergoing more bone loss, allow for regular im-
plant placement, compared with non-molar sites, where the impact
of physiologic bone resorption is proportionally larger. This finding
is in agreement with the results published in a previous SR (Avila-
Ortiz et al., 2019), in which data from non-molar and molar sites
were combined, that reported that 33.3%–66% of the untreated ex-
traction sites required ancillary bone grafting prior to or at the time
of implant placement. Interestingly, one trial including only maxillary
molar sites revealed that 100% of the patients needed sinus aug-
mentation procedures for implant placement purposes (Cha et al.,
2019). However, there was a lack of information regarding whether
bone grafting augmentation procedures were needed to compen-
sate the alveolar ridge resorption following tooth extraction, or
whether there was a pre-existing vertical height deficiency at base-
line. Therefore, this study was excluded from the analysis pertaining
to this parameter due to unclear description. This contrasts with the
findings from a study conducted by Rasperini et al. (2010) who re-
ported that only 37.5% maxillary molar sites required sinus augmen-
tation procedures after tooth extraction, and this requirement was
more frequent in partially damaged sockets. It is important to note
that this outcome is associated with a high degree of methodological
variability since bone height and width requirements may vary sig-
nificantly depending on implant dimension (i.e. length and diameter)
preferences.
5  |  CO N C LU S I O N S
1. Based on the qualitative and quantitative analyses performed
as part of this SR, it can be concluded that more reduction
in the alveolar ridge dimensions can be expected in molar
sites in all dimensions, except for vertical mid-facial changes,
compared with non-molar sites after a variable post-extraction
healing period ranging from 2 to 9 months.
2. Ridge resorption is more pronounced in the horizontal dimension,
followed by vertical mid-facial and mid-lingual changes.
3. Facial bone thickness upon extraction seems to be strongly asso-
ciated with the extent and magnitude of alveolar bone resorption.
The thicker the facial bone, the less the ridge resorption.
4. According to the current base of evidence, non-molar sites are
associated with an increased need for ancillary bone grafting pro-
cedures prior to or at the time of implant placement compared
with molar sites (69.7% vs 45.9%, respectively).
5. Future studies should improve the report of information on local
(i.e. socket anatomy and integrity, soft tissue thickness, keratinized
 |
142      COUSO-QUEIRUGA ET AL.

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CONFLIC T OF INTEREST
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The authors have no conflicts of interest to report pertaining to the Covani, U. (2008). Xenograft versus extraction alone for ridge
conduction of this SRs. This study was supported by the University preservation after tooth removal: A clinical and histomorphomet-
of Iowa College of Dentistry Department of Periodontics Graduate ric study. Journal of Periodontology, 79(8), 1370–1377. https://doi.
org/10.1902/jop.2008.070628
Student Research Fund.
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R., Marchionni, S., Calvo-Guirado, J. L., Covani, U., & Nannmark, U.
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initial entries, selected the articles and collected the data. S.S. and domized controlled clinical trial. Journal of Clinical Periodontology,
44(2), 204–214. https://doi.org/10.1111/jcpe.12655
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Barootchi, S., Wang, H. L., Ravida, A., Ben Amor, F., Riccitiello, F., Rengo,
lysed the data. E.C.Q. and G.A.O. led the writing. S.S. and L.C. criti- C., & Sammartino, G. (2019). Ridge preservation techniques to avoid
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DATA AVA I L A B I L I T Y
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section.
APPENDIX 1
Search methods
The search strategy followed was:
#1 Tooth extraction OR extraction OR dental extraction OR ex-
traction, tooth OR tooth socket
#2 Alveolar ridge preservation OR ridge preservation OR socket
grafting OR socket filling OR socket preservation OR socket graft
OR guided bone regeneration OR alveolar ridge augmentation
#3 #1 OR #2
A complementary manual search of articles published in rel-
evant scientific journals (i.e. Journal of Clinical Periodontology,
Journal of Periodontology, International Journal of Periodontics
and Restorative Dentistry, Clinical Implant Dentistry and Related
Research, Clinical Oral Implants Research, Implant Dentistry, Journal
of Oral Implantology, International Journal of Oral and Maxillofacial
Implants, Journal of Oral and Maxillofacial Surgery, International
Journal of Oral Implantology, European Journal of Oral Implantology)
from 1 January 2020 to 15 August 2020 was performed. Additionally,
cross-referencing of cited references in 32 SRs on the topic published
until 15 August 2020 was conducted (Al Yafi et al., 2019; Annunziata
et al., 2018; Avila-Ortiz et al., 2014, 2019; Barootchi et al., 2019;
Bassir et al., 2018; Canellas et al., 2019; Chan et al., 2013; De Risi
et al., 2015; Del Fabbro et al., 2017; Faria-Almeida et al., 2019;
Horvath et al., 2013; Iocca et al., 2017; Jambhekar et al., 2015; Lee
et al., 2018; MacBeth et al., 2017; Majzoub et al., 2019; Mardas et al.,
2015; Moraschini & Barboza, 2015; Moraschini & Barboza Edos,
2016; Morjaria et al., 2014; Moslemi et al., 2018; Natto et al., 2017;
Pranskunas et al., 2019; Stumbras et al., 2019; Tan et al., 2012; Ten
Heggeler et al., 20112011; Troiano et al., 2018; Van der Weijden
et al., 2009; Vignoletti et al., 2012; Vittorini Orgeas et al., 2013;
Willenbacher et al., 2016).
Risk of bias
The following domains were assessed for RCTs:
1. Randomization process
2. Deviations from intended interventions (assignment)
3. Missing outcome data
4. Measurement of the outcome
5. Selection of the reported result
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      145
How to cite this article: Couso-Queiruga E, Stuhr S, Tattan M,
Chambrone L, Avila-Ortiz G. Post-extraction dimensional
changes: A systematic review and meta-analysis. J Clin
Periodontol. 2021;48:127–145. https://doi.org/10.1111/
jcpe.13390
To demonstrate the overall risk of bias, each included study was
categorized as being at low, some concerns or high risk of bias ac-
cording to the following criteria:
1. Low risk of bias: the trial was judged to be at low risk of
bias for all domains for this result.
2. Some concerns of bias: the trial was judged to raise some con-
cerns in at least one domain for this result, but not to be at high
risk of bias for any domain.
3. High risk of bias: the trial was judged to be at high risk of bias in at
least one domain for this result or have some concerns for multi-
ple domains in a way that substantially lowers confidence in the
result.
The following domains were assessed for non-RCTs:
1. Pre-intervention
• Bias due to confounding
• Bias in selection of participants into the study
2. At intervention
• Bias in classification of interventions
3. Post-intervention
• Bias due to deviations from intended interventions
• Bias due to missing data
• Bias in measurement of outcomes
• Bias in selection of the reported result
To demonstrate the overall risk of bias, each included study was
categorized as being low, moderate, serious and critical risk of bias or
no information according to the following criteria:
1. Low risk of bias: the study is judged to be at low risk of bias
for all domains.
2. Moderate risk of bias: the study is judged to be at low or moderate
risk of bias for all domains.
3. Serious risk of bias: the study is judged to be at serious risk of bias
in at least one domain, but not at critical risk of bias in any domain.
4. Critical risk of bias: the study is judged to be at critical risk of bias
in at least one domain.
5. No information: there is no clear indication that the study is at
serious or critical risk of bias, and there is a lack of information in
one or more key domains of bias (a judgement is required for this).