Systematic Review and Meta-Analysis of

Hard Tissue Outcomes of Alveolar Ridge Preservation

Seyed Hossein Bassir, DDS, DMSc1/Muhanad Alhareky, BDS, MS, DMSc2/
Buddhathida Wangsrimongkol, DDS, DMSc3/Yinan Jia, MS, MPH, RD, CDN4/
Nadeem Karimbux, DMD, MMSc5

Purpose: Alveolar ridge preservation procedures have been advocated to minimize postextraction dimensional
loss. There is a need for systematic analyses of clinical factors affecting the outcomes of these procedures in
order to improve their clinical outcomes. This systematic review and meta-analysis aimed to assess the efficacy
of alveolar ridge preservation procedures in terms of hard tissue dimensional changes and to determine
clinical factors affecting outcomes of these procedures. Materials and Methods: Studies comparing alveolar
ridge preservation procedures with tooth extraction alone that reported quantitative outcomes for hard tissue
dimensional changes were included. The primary outcome variable was horizontal dimensional changes of
alveolar bone. Subgroup analyses evaluated effects of wound closure, flap elevation, type of grafting materials,
use of barrier membranes, use of growth factors, socket morphology, and the position of teeth on outcomes of
alveolar ridge preservation procedures. Results: Twenty-one studies were included, and quantitative analyses
were performed for seven outcome variables. Significant differences between alveolar ridge preservation and
control sites were found for six outcome variables, all favoring alveolar ridge preservation procedures. The
magnitude of effect for the primary outcome variable (horizontal dimensional changes of alveolar bone) was
1.86 mm (95% CI = 1.44, 2.28; P < .001). This magnitude of effect for the primary variable (as determined by
subgroup analysis) was also significantly affected by type of wound closure (P = .033), type of grafting materials
(P = .001), use of barrier membranes (P = .006), use of growth factors (P = .003), and socket morphology
(P < .001). Conclusion: Alveolar ridge preservation procedures are effective in minimizing postextraction hard
tissue dimensional loss. The outcomes of these procedures are affected by morphology of extraction sockets,
type of wound closure, type of grafting materials, use of barrier membranes, and use of growth factors. Int J
Oral Maxillofac Implants 2018;33:979–994. doi: 10.11607/jomi.6399

Keywords: alveolar ridge augmentation, alveolar ridge preservation, bone augmentation procedures, dental
implants, evidence-based dentistry, meta-analysis, socket healing, tooth extraction

1Formerly

Postgraduate Resident, Division of Periodontology,
Department of Oral Medicine, Infection, and Immunity,
Harvard School of Dental Medicine, Boston, Massachusetts,
USA; Currently Assistant Professor and Director of Advanced
Specialty Education Program in Periodontics, Department
of Periodontology, School of Dental Medicine, Stony Brook
University, Stony Brook, New York, USA.
2 Assistant Professor, Preventive Dental Sciences Department,
T
he outcome of implant therapy is no longer defined
only by successful osseointegration. Rather, the
success depends on a variety of factors that affect the
implant-prosthetic complex, including the health and
stability of peri-implant soft and hard tissues, esthetic

College of Dentistry, Imam Abdulrahman Bin Faisal University,

Dammam, Saudi Arabia.
3Craniofacial Orthodontic Fellow, Department of Orthodontics
and Pediatric Dentistry, School of Dentistry, University of
Michigan, Ann Arbor, Michigan, USA; Instructor, Department of
Orthodontics, Khon Kaen University, Khon Kaen, Thailand.
4Postgraduate Student, Tufts University School of Medicine,
Boston, Massachusetts, USA.
5Professor, Periodontology, and Associate Dean, Academic
Affairs, Tufts University School of Dental Medicine, Boston,
Massachusetts, USA.
This work was partially presented as a poster at the 31st Annual
Meeting of the Academy of Osseointegration (San Diego, 2016)
and ITI Congress North America (Chicago, 2016).
Correspondence to: Dr Seyed Hossein Bassir, 104 Rockland
Hall, Stony Brook School of Dental Medicine, Stony Brook, NY
11794-8703, USA. Email: seyed.bassir@stonybrookmedicine.edu
©2018 by Quintessence Publishing Co Inc.
outcomes, and patient satisfaction.1–3 A crucial prereq-
uisite for the success of implant therapy is placement
of dental implants in an ideal position since it directly
affects the esthetic outcomes as well as the long-term
stability of peri-implant tissue.1,4–6 However, postex-
traction alveolar ridge dimensional changes that occur
as a result of postextraction healing and the bone re-
modeling process can hinder placement of implants in
the ideal position, which may compromise the success
of implant treatment.7,8
Alveolar ridge dimensional changes after tooth
extraction have been widely studied.7–9 A systematic
review by Tan et al reported that the mean amount of
alveolar ridge resorption during the first 6 months fol-
lowing tooth extraction is 3.79 ± 0.23 mm in horizontal
dimension and 1.24 ± 0.11 mm in vertical dimension.9

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Bassir et al
Another systematic review by Van der Weijden and
colleagues reported that a mean clinical loss of 3.87
± 0.82 mm in horizontal dimension and 0.64 ± 0.19
mm in vertical dimension occurs following tooth ex-
traction.8 Considering the magnitude of alveolar ridge
resorption, reducing postextraction dimensional loss
is decisive in achieving the placement of the dental
implant in the optimal position. Hence, alveolar ridge
preservation procedures have been advocated to pre-
vent or reduce this postextraction dimensional loss.
Numerous studies have investigated the efficacy
of alveolar ridge preservation procedures performed
using various surgical techniques and a variety of bio-
materials.10–20 However, these studies reported vary-
ing degrees of success to preserve the architecture of
residual alveolar ridges. Considering the number of
studies published on the efficacy of alveolar ridge pres-
ervation procedures, the question today is no longer
simply identifying whether alveolar ridge preservation
procedures can prevent postextraction bone loss, but
instead determining in which clinical scenarios these
procedures are most beneficial and which surgical ap-
proaches are most effective. Indeed, there is still con-
siderable controversy regarding the ideal approach to
perform alveolar ridge preservation.
The effects of different clinical techniques on the
outcome of alveolar ridge preservation procedures
have been somewhat addressed in two systematic
reviews.14,20 A meta-analysis by Avila-Ortiz and col-
leagues attempted to assess the effects of clinical vari-
ables such as flap elevation, use of barrier membrane,
and type of grafting material on the outcomes of al-
veolar ridge preservation procedures.20 This system-
atic review, however, used very strict inclusion criteria
such as including randomized controlled trials (RCTs)
that had only a parallel group design in which alveolar
ridge preservation procedures were performed only
in non-molar teeth with utilization of a grafting mate-
rial. Although very strict inclusion criteria may reduce
the heterogeneity of effect estimate, it may compro-
mise the generalizability of the findings. In addition, it
should be mentioned that the effects of the aforemen-
tioned clinical variables in Avila-Ortiz et al’s study were
assessed using subgroup analyses of eight included
studies. The results of subgroup analysis must be in-
terpreted with caution when fewer than 10 studies are
included in the analysis, as the analysis would not have
enough power to detect a true effect.21 A recent Bayes-
ian Network meta-analysis of six RCTs also attempted
to indirectly rank the efficacy of different grafting ma-
terials for alveolar ridge preservation procedures.14
However, the aforementioned limitations apply for this
study as well and limit the generalizability of its find-
ings. Thus, there is still a need for systematic analyses of
clinical factors affecting the outcomes of alveolar ridge
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preservation procedures to improve the outcomes of
these procedures and provide evidence-based clinical
recommendations.
The present systematic review and meta-analysis
primarily aimed to compare the efficacy of alveo-
lar ridge preservation procedures with that of tooth
extraction with no intervention in terms of postex-
traction hard tissue dimensional changes measured
clinically or radiographically. The secondary aim of this
study was to explore the effects of potential clinical
variables that may affect the outcome of alveolar ridge
preservation procedures. The focused PICO question
was as follows: “Are there differences in clinical or ra-
diographic postextraction hard tissue dimensional
changes when comparing alveolar ridge preservation
procedures to tooth extraction with no intervention?”
MATERIALS AND METHODS
This systematic review and meta-analysis was per-
formed according to PRISMA guidelines.22
Inclusion and Exclusion Criteria
A PICO (Population, Intervention, Comparator, and
Outcome) framework was utilized to guide the inclu-
sion or exclusion of studies in this systematic review.
Studies involving human subjects who required single
or multiple tooth extraction (Population) were consid-
ered for inclusion in this study. To be eligible for inclu-
sion, studies had to have a test group (Intervention),
in which patients received alveolar ridge preservation
procedures after tooth extraction. All included trials
had to have a control group (Comparator), in which pa-
tients had tooth extraction (EXT) without any further
intervention. All studies also had to provide quantita-
tive measurements of either clinical or radiographic
postextraction hard tissue dimensional changes
(Outcomes).
The exclusion criteria were as follows: (1) non-Eng-
lish citations, in vitro studies, animal studies, editorials,
reviews, case-control and cross-sectional studies, case
reports, or case series; (2) trials involving extraction of
only third molars; (3) studies with any other interven-
tions that could have affected the outcome of alveolar
ridge preservation such as soft tissue grafting or use
of soft tissue biomaterials; (4) studies involving any in-
tervention in the control group other that extraction
alone such as use of any biomaterial or any wound
dressing; (5) studies that did not clearly describe the
experimental methodology or outcome parameters;
(6) studies that did not present data for outcome vari-
ables of interest of the present review; (7) studies in-
volving the same population and reporting the same
outcome variable as other included studies; (8) failure

to report quantitative outcomes or present the results
in a manner that does not allow the pooling of data.
Search Strategy and Study Selection
The electronic search included MEDLINE and EMBASE
databases from inception until September 2016. De-
tails of the electronic search strategy are presented in
the Appendix (see online version of this article at www.
quintpub.com). Moreover, a manual search in the ref-
erence lists of included studies and relevant excluded
studies was conducted. The results of the systematic
search were reviewed independently by two authors
(S.B. and M.A.). Disagreements regarding the inclusion
of the studies were resolved through discussion and
consensus, and by consulting a third author (N.K.).
Data Extraction and Risk of Bias Assessment
Two reviewers (S.B. and B.W.) independently conduct-
ed the data extraction. Using a predetermined data
extraction table, the data for the following variables
were extracted from included studies: (1) general in-
formation: first author, title, year of publication, jour-
nal, study design, number of groups, country of origin,
setting (private practice vs academic setting), funding
source, and length of follow-up; (2) Patient characteris-
tics: number of subjects in each group, baseline demo-
graphic information (age, number of male and female
subjects), number of smokers in each group, and num-
ber of dropouts; (3) extraction socket features: number
of sites in each group, type of arch (maxilla, mandible,
or both), position of teeth (incisors, canines, premo-
lars, or molars), and morphology of socket (intact or
damaged); (4) surgical considerations: type of grafting
material used, type of barrier membrane used, use of
growth factors, flap elevation, and type of soft tissue
closure; and (5) outcomes: outcome variables, evalua-
tion method, and results.
Any discrepancies between reviewers were resolved
by discussion and consensus, and by consulting a third
author (N.K.) if needed. The corresponding authors
were contacted for relevant missing data.
The risk of bias was assessed using the Cochrane
Collaboration’s tool for assessing risk of bias.21,23 De-
tails of data extraction and risk of bias assessment ap-
pear in the Appendix.
Data Analysis
The primary outcome variable of the present study
was mean postextraction horizontal dimensional
changes of alveolar bone. The secondary outcome
variables were mean postextraction vertical dimen-
sional changes of alveolar bone buccally, lingually, me-
sially, and distally; the amount of socket fill; and bone
height dimensional changes measured on cone beam
computed tomography. For all analyses, data from the
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Bassir et al
included studies were pooled to estimate the effect
size, expressed as weighted mean differences and 95%
confidence intervals (CI). For studies with more than
one eligible test group and only one control group,
each test group was included as a separate compari-
son, and the sample size of the control group was
divided out approximately evenly among the com-
parisons to avoid duplicate counting of participants.
Random-effects analysis was used to perform the me-
ta-analyses for all except one outcome variable (distal
alveolar bone height dimensional changes) due to the
presence of significant heterogeneity across studies.
Heterogeneity across studies was characterized using
Cochran-Q statistic and I2 statistic tests.21
Preplanned subgroup analyses were performed
for the primary outcome variable to examine the ef-
fects of the following clinically relevant characteristics
on the outcome of alveolar ridge preservation: type
of wound closure, elevation of flap, type of grafting
materials, use of barrier membranes, use of growth
factors, morphology of extraction sockets, position of
teeth, and type of arch. In addition, preplanned meta-
regression analyses were conducted to evaluate pos-
sible heterogeneity in treatment effects of the primary
outcome variable according to the following study
characteristics: study type (RCT vs CT), study design
(split-mouth design vs parallel group design), funding
(reported vs not reported), and follow-up period (con-
tinuous variable).
Sensitivity analyses were carried out for the primary
outcome variable to test the robustness of the conclu-
sions of this meta-analysis. In each sensitivity analysis,
the effect size was estimated after eliminating: (1) non-
randomized clinical trials, (2) split-mouth design stud-
ies, (3) studies with no reported source of funding, (4)
studies with less than 4 months follow-up period, or (5)
studies with more than two “No” or “Unclear” domains
after assessment of risk of bias.
Potential publication bias for the primary outcome
variable was explored by the funnel plots, and it was
examined statistically by using both Begg and Mazum-
dar rank correlation test and Egger’s regression test.
Statistical analyses were conducted using the Com-
prehensive Meta-Analysis software (Version 3, Biostat)
and Stata Statistical software (StataCorp) packages.
RESULTS
Study Selection
A flow diagram of the search results is illustrated in Fig
1. The literature search identified a total of 1,698 cita-
tions, among which 1,637 were excluded after screen-
ing of the titles and abstracts of the articles. Next, the
full text of the remaining 61 articles were reviewed by
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Bassir et al

Fig 1   Study selection flow diagram.

Identification

MEDLINE EMBASE Manual search

(n = 1,487) (n = 284) (n = 8)

Records after duplicates eliminated

(n = 1,698)
Screening

Abstracts screened
(n = 313)
Eligibility

Full-text screened
(n = 61)
Included

Studies included in the meta-analysis

(n = 21)

Horizontal dimensional Buccal bone height Mesial bone height

changes of alveolar dimensional changes dimensional changes
bone (n = 14) (n = 14) (n = 8)
Meta-analyses

Distal bone height Lingual bone height

Socket fill
dimensional changes dimensional changes
(n = 6)
(n = 8) (n = 6)

Bone height
dimensional changes
measured on CBCT
(n = 5)

two reviewers (S.B. and M.A.), and of these, an addi-
tional 40 were excluded. The reasons for exclusion of
these studies are presented in the Appendix Table 1.
In total, 21 articles met the inclusion criteria (Table 1).
Study Characteristics
Seventeen studies provided data on the clinical postex-
traction dimensional changes of alveolar bone (stud-
ies 1 to 17 [Tables 1a and 1b]), and five studies used
three-dimensional computed tomography to measure
the changes in alveolar bone dimensions (studies 17
to 21). Characteristics of the included studies are pre-
sented in Tables 1a and 1b.
Seventeen out of 21 included studies were RCTs
(studies 1 to 3, 6 to 10, 12 to 15, 17 to 21), and split-
mouth design was utilized in six studies (studies 4, 6,
11, 12, 17, and 21). The follow-up period ranged from
2 to 9 months, and only one of the included studies
had a follow-up period of less than 3 months (study 8).
All except two studies (studies 16 and 18) were solely
conducted in academic settings. The sources of fund-
ing were not reported in the majority of studies (stud-
ies 1 to 3, 5, 6, 8, 9, 11, 12, 16, 17, 20, 21). Five studies
were fully or partially funded by grants from industry
(studies 4, 13, 14, 18, and 19), and in two studies, den-
tal materials were provided by companies (studies 10
and 15). Only one study was funded by governmental
grants (study 7). Four studies included only maxillary
extraction sites (studies 1, 14, 15, 18), and one study in-
cluded only mandibular extraction sockets (study 20).
The other studies included extraction sockets in both
arches. One study included only incisor and canine
extraction sockets (study 14), two studies included
only premolar extraction sockets (studies 6 and 8), and
two studies solely included molar extraction sockets
(studies 15 and 20). The majority of studies included
a combination of anterior and premolar teeth (studies
1, 2, 4, 9, 11, 12, 17 to 19, and 21), while two studies
included a combination of premolar and molar teeth
(studies 3 and 7). All teeth were included in the other
four studies (studies 5, 10, 13, and 16). Three studies
only included damaged extraction sockets (studies 5,
18, and 20), while five studies solely included intact ex-
traction sockets (studies 1, 2, 6, 8, and 17). Five studies
did not use any grafting material for ridge preservation
procedures (studies 8, 11, 12, 18, and 21), two of which
used guided tissue regeneration procedures (studies
11 and 12), and the other three utilized growth factors

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 Bassir et al

Table 1a   Characteristics of Included Studies: Study and Patient Characteristics

Study Characteristics Patient characteristics
Follow-up Patients Mean Smokers
Study Design Country Setting Funding (mo) Groups (n) age ± SD (y) (n)a
Studies with clinical outcome variables
1 Aimetti et RCT; Parallel Italy Academic Unknown 3 Test 22 50.8 ± 8.4 0
al31 group Control 18 51.8 ± 8.6 0
2 Barone et RCT; Parallel Italy Academic Unknown 7–9 Test 20 26–69c 0
al32 group Control 20 0
3 Barone et RCT; Parallel Italy Academic Unknown 4 Test 29 41.8 ± 14 0
al33 group Control 29 39.9 ± 15.5 0
4 Camargo et CT; split- Serbiab Academicb Industry 6 Test 16 44 ± 15.9 Not
al34 mouth supported Control reported
5 Casado et CT; Parallel Brazil Academic Unknown 4 Test 1 19 Not reported Not
al35 group Test 2 reported
Test 3
Control
6 Festa et al36 RCT; Italy Academic Unknown 6 Test 15 28–58c 0
split-mouth Control 0
7 Goh et al37 RCT; Parallel Singapore Academic Non- 6 Test 7 46.8 ± 12.1 0
group Industry Control 7 46.9 ± 9.2 0
8 Hauser et RCT; Parallel Switzerland Academicb Unknown 2 Test 1 9 47.11 ± 5.57 Not
al38 group Test 2 6 50.33 ± 2.4 reported
Control 8 45.62 ± 1.84

9 Iasella et RCT; Parallel US Academicb Unknown 4–6 Test 12 51.5 ± 13.6 Not
al39 group Control 12 reported
10 Kotsakis et RCT; Parallel US Academic Industry 5 Test 1 8 39.8 0
al40 group associated Test 2 10 43.3 0
Control 6 43.8 0
11 Lekovic et CT: split- Serbia Academic Unknown 3–6 Test 10 49.8 Not
al41 mouth Control reported
12 Lekovic et RCT; split- Serbia Academic Unknown 6 Test 16 52.6 ± 11.8 Not
al42 mouth Control reported
13 Mayer et RCT; Parallel Israel Academic Industry 4 Test 36 Not reported 0
al43 group supported Control 0
14 Pelegrine et RCT; Parallel Brazil Academic Industry 6 Test 7 47.5 ± 10.3 0
al44 group supported Control 6 0
15 Rasperini et RCT; Parallel Italya Academic Industry 3 and 6 Test 7 54 0
al45 group associated Control 9 0
16 Serino et CT; Parallel Italy Private Unknown 6 Test 45 35–64c Not
al46 group practicea Control reported
Studies with both clinical and radiograph outcome variables
17 Madan et RCT; split- India Academic Unknown 6 Test 15 20–45c Not
al47 mouth Control reported
Studies with radiograph outcome variables
18d Fiorellini et RCT; Parallel US Academic Industry 4 Test 1 22 47.4 Not
al48 group and private supported Test 2 21 reported
practice Control 20
19d Jung et al49 RCT; Parallel Switzerland Academic Industry 6 Test 10 59 ± 11 1
group supported Control 10 48 ± 15 1
20 Pang et al 50 RCT; Parallel China Academic Unknown 6 Test 1 15 43 0
group Test 2 15 0
Control 1 15 0
Control 2 15 0
21 Temmerman RCT; split- Belgium Academic Unknown 3 Test 22 54 ± 11 0
et al51 mouth Control 0
aNumber of heavy smokers (> 10 cigarettes/day). bInformation provided by the authors.
cAge range; mean age was not reported. dNot all experimental arms were included in this systematic review.
CT = controlled trial (non-randomized); mo = months; RCT = randomized controlled trial; SD = standard deviation.

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Bassir et al

Table 1b   Characteristics of Included Studies: Study and Patient Characteristics

No. of sites Extraction socket features
Type of
Study Groups Baseline Follow-up a Location teeth Morphology
1 Aimetti et al31 Test 22 22b Maxilla Non-molarb Intact
Control 18 18b
2 Barone et al32 Test 20 20 Both Non-molar Intact
Control 20 20
3 Barone et al33 Test 29 29 Both Premolar and molar Mixed
Control 29 29
4 Camargo et al34 Test 16 16 Bothb Non-molar Mixedb
Control 16 16
5 Casado et al35 Test 1 11 11 Both All Damaged
Test 2 12 12
Test 3 12 12
Control 11 11
6 Festa et al36 Test 15 15 Both Premolar Intact
Control 15 15
7 Goh et al37 Test 7 6 Both Premolar Mixedb
Control 7 7 and molar
8 Hauser et al38 Test 1 9 9 Both Premolar Intactb
Test 2 6 6
Control 8 7
9 Iasella et al39 Test 12 12 Both Non-molar Mixedb
Control 12 12
10 Kotsakis et al40 Test 1 12 12 Both All Mixed
Test 2 12 12
Control 6 6
11 Lekovic et al41 Test 10 10 Both Non-molar Mixedb
Control 10 10
12 Lekovic et al42 Test 16 16 Both Non-molar Mixedb
Control 16 16
13 Mayer et al43 Test 20 14 Both All Mixedb
Control 20 15
14 Pelegrine et al44 Test 15d 15d Maxilla Incisor and canine Mixed
Control 15d 15d
15 Rasperini et al45 Test 7 6 Maxilla Molar Mixed
Control 9 8
16 Serino et al46 Test NR 26 Both All Mixedb
Control NR 13
Studies with both clinical and radiograph outcome variables
17 Madan et al47 Test 30 30 Both Non-molar Intact
Control 30 30
Studies with radiograph outcome variables
18c Fiorellini et al48 Test 1 95 95 Maxilla Non-molar Damaged
Test 2
Control
19c Jung et al49 Test 10 10 Both Non-molar Mixed
Control 10 10
20 Pang et al50 Test 1 15 15 Mandible Molar Damagedf
Test 2 15 15 Damagedg
Control 1 15 15 Damagedf
Control 2 15 15 Damagedg
21 Temmerman et al51 Test 22 22 Both Non-molar Mixed
Control 22 22
aNumber of sites at baseline minus dropouts. bInformation provided by the authors. cNot all experimental arms were included in this systematic
review. d0.75 mg/mL delivered on absorbable collagen sponge; total mean dose per socket 0.9 mg. e1.5 mg/mL delivered on absorbable collagen
sponge; total mean dose per socket 1.9 mg. fExtraction sockets with 3- to 5-mm buccal bone defect. gExtraction sockets with 5 mm or more
buccal bone defect.
BMP-2 = bone morphogenetic protein 2; NA = not applicable; NR = not reported; PRF = platelet-rich fibrin.

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 Bassir et al

to perform ridge preservation procedures (studies 8,

18, and 21). Alloplasts and xenografts were the most
Surgical considerations commonly used grafting materials, which were utilized
Grafting Growth Primary in eight (studies 1, 4, 7, 10, 13, 16, 17, and 19) and 7 of
material Membrane factor Flap closure
the studies (studies 2, 3, 5, 6, 10, 15, and 20), respec-
Alloplast No No No No
NA NA NA
tively. Freeze-dried allograft (study 9) and autogenous
bone marrow graft (study 14) were each used only in
Xenograft Resorbable No Yes Yes
NA NA NA one study. Barrier membranes were utilized in 10 stud-
Xenograft Resorbable No No No ies (studies 2 to 6, 9, 11, 12, 15, and 20), and only one of
NA NA NA these studies used a nonresorbable membrane (study
Alloplast Resorbable No Yes No 11). Ridge preservation procedures were performed
NA NA NA using growth factors in four studies (studies 5, 8, 18,
Xenograft No BMP-2 Yes Yes and 21), three of which used neither grafting materials
Xenograft Resorbable BMP-2 nor barrier membranes (studies 8, 18, and 21). Recom-
No Resorbable No
NA NA NA binant human bone morphogenetic protein-2 (stud-
Xenograft Resorbable No Yes Yes ies 5 and 18) and platelet-rich fibrin (studies 8 and
NA NA 21) were each used in two studies. The majority of the
Alloplast No No Yes Yes studies raised a mucoperiosteal flap to perform ridge
NA NA NA preservation surgeries (studies 2, 4 to 9, 11 to 14, 16 to
No No PRF No Nob 18, and 20). Ten of these studies attempted to achieve
No No PRF Yes primary closure (studies 2, 5 to 7, 11 to 14, 18, and 20).
NA NA NA No
The results of risk of bias assessment are presented
Allograft Resorbable No Yes No
NA NA NA in Appendix Table 2.
Xenograft No No Nob No
Alloplast No No Quantitative Analyses
NA NA NA It was possible to perform meta-analyses for the fol-
N Non-resorbable No Yes Yes lowing clinically measured outcome variables: hori-
NA NA NA
zontal dimensional changes of alveolar bone (primary
N Resorbable No Yes Yes outcome variable; reported in 14 studies), buccal bone
NA NA NA
height dimensional changes (reported in 14 studies),
Alloplast No No Yes Yes
NA NA NA
mesial bone height dimensional changes (reported in
eight studies), distal bone height dimensional chang-
Autologous No No Yes Yes
NA NA NA es (reported in eight studies), lingual bone height di-
Xenograft Resorbable No No No mensional changes (reported in six studies), socket fill
NA NA NA (vertical bone fill in the extraction sockets; reported
Alloplast No No Yes No in six studies); it was only possible to perform meta-
NA NA NA analysis in one radiographically measured outcome
variable: bone height dimensional changes measured
Alloplast No No Mixedb No on cone beam computed tomography (reported in 5
NA NA NA studies).

No No BMP-2d Yes Yes Horizontal Dimensional Changes of Alveolar

No No BMP-2e Bone (Primary Outcome Variable)
NA NA No
The meta-analysis for horizontal dimensional changes
Alloplast No No No No
NA NA NA
of alveolar bone was performed for 14 studies (stud-
ies 1 to 14). Three studies had more than one interven-
Xenograft Resorbable No Yes Yes
Xenograft Resorbable No tion group qualified for the inclusion in the systematic
NA NA NA review (studies 5, 8, and 10). In total, 348 patients
NA NA NA
participated in the included studies for this outcome
No No PRF No No variable. The total number of experimental sites was
NA NA NA
241, and the total number of control sites was 188.
The forest plot of the meta-analysis for horizontal di-
mensional changes of alveolar bone is illustrated in Fig
2a. Meta-analysis showed a significant difference be-
tween experimental and control sites (P < .001), which

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Bassir et al
favored alveolar ridge preservation with the clinical
magnitude of 1.86 mm (95% CI = 1.44, 2.28; heteroge-
neity I2 = 79.08%; τ = 0.71).
Preoperative and postoperative (final) horizontal
bone dimensions were reported in 11 studies (studies
1 and 2, 4 to 6, 9 to 14). The weighted mean preopera-
tive horizontal bone dimensions were 7.09 mm (95%
CI = 5.22, 8.96) and 7.08 mm (95% CI = 5.98, 8.19) in the
experimental sites and control sites, respectively. The
weighted mean final horizontal bone dimension for
the experimental group was 6.33 mm (95% CI = 5.52,
7.14) and for the control groups was 4.45 mm (95% CI
= 3.48, 5.43).
Buccal Alveolar Bone Height Dimensional
Changes
Fourteen studies (studies 1 to 4, 6, 7, 9, 11 to 17) involv-
ing a total of 358 subjects reported quantitative data
on buccal alveolar bone height dimensional changes.
The total number of sockets that underwent alveo-
lar ridge preservation was 229, and the total number
of sockets that underwent extraction alone was 215.
Quantitative analysis significantly favored the experi-
mental group with the clinical magnitude of 1.55 mm
(P < .001; 95% CI = 0.70, 2.4; heterogeneity I2 = 94.56%;
τ = 1.43; Fig 2b).
Mesial Alveolar Bone Height Dimensional
Changes
The quantitative analysis for mesial height dimen-
sional changes of alveolar bone was done for eight
studies (studies 1 to 3, 6, 7, 9, 16, and 17). In total, 251
patients, with 160 experimental sites and 144 control
sites, participated in these studies. As shown in Fig 3a,
a significant weighted mean difference of 0.59 mm (P <
.001; 95% CI = 0.31, 0.87; heterogeneity I2 =56.61%; τ =
0.28) was found in favor of alveolar ridge preservation
for this outcome variable.
Distal Alveolar Bone Height Dimensional
Changes
The studies that reported distal bone height dimen-
sional changes were the same studies that reported
mesial bone height dimensional changes (studies
1 to 3, 6, 7, 9, 16, and 17) with an identical number
of experimental and control sites (160 experimental
and 144 control sites). Meta-analysis demonstrated a
significant weighted mean difference of 0.33 mm (P <
.001; 95% CI = 0.15, 0.54; heterogeneity I2 = 12.81%; τ
= 0.10) in favor of alveolar ridge preservation (Fig 3b).
Lingual Alveolar Bone Height Dimensional
Changes
The quantitative analysis for this outcome variable was
performed for six studies (studies 1 to 3, 6, 9, and 17).
986 Volume 33, Number 5, 2018
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These studies included a total number of 192 subjects
with 128 experimental sockets and 124 control sock-
ets. The analysis revealed an overall weighted benefit
of 1.14 mm (P < .001; 95% CI = 0.58, 1.71; heterogene-
ity I2 = 80.33%; τ = 0.60) for alveolar ridge preservation
compared with extraction alone (Fig 4a).
Socket Fill
Quantitative data on vertical bone fill in the extraction
sockets were reported in six trials (studies 1, 4, 11, 12,
14, and 15). A total of 111 subjects, with 77 alveolar
ridge preservation sites and 74 extraction alone sites,
participated in these trials. Meta-analysis showed a
weighted mean difference of 1.05 mm (P = .054; 95%
CI = –0.02, 2.12; heterogeneity I2 = 55.04%; τ = 0.90; Fig
4b) between the two groups for this variable.
Bone Height Dimensional Changes Measured
on Cone Beam Computed Tomography
Among radiographic hard tissue dimensional change
variables, meta-analysis was only possible for bone
height dimensional changes measured on cone beam
computed tomography. The quantitative data for this
variable were pooled from five studies (studies 17 to
21) including 180 patients with 133 experimental sites
and 111 control sites. As illustrated in Fig 5, a signifi-
cant weighted mean difference of 1.36 mm (P < .001;
95% CI = 0.84, 1.87; heterogeneity I2 = 83.67%; τ = 0.53)
favoring the experimental group was found.
Subgroup Analyses and Meta-Regression
Results of subgroup analyses for eight clinically rele-
vant characteristics are presented in Table 2. Subgroup
analyses demonstrated that achieving primary closure
had a significant positive effect (P = .033) on the pres-
ervation of horizontal dimensions of alveolar ridge.
The overall weighted benefit of alveolar ridge preser-
vation was 2.18 mm (95% CI = 1.64, 2.72) when primary
closure was achieved, while the weighted benefit was
1.44 mm (95% CI = 1.03, 1.86) when ridge preservation
procedures were performed without achieving prima-
ry closure (Appendix Fig 1). The analyses also revealed
that the effect of type of grafting materials on the out-
come of alveolar ridge preservation was significant (P
= .001). It was found that the use of alloplasts resulted
in less desirable outcomes. The clinical magnitude of
benefit of alveolar ridge preservation was only 0.91
mm (95% CI = 0.30, 1.52) when alloplasts were used
(Appendix Fig 2). In addition, use of barrier mem-
branes had significant positive effects (P = .006) on the
outcomes of alveolar ridge preservation (Appendix
Fig 3). Moreover, analyzing the effect of use of growth
factors demonstrated that the weighted benefits of al-
veolar ridge preservation were 1.73 mm (95% CI = 1.28,
2.18) when no growth factor was used, 2.84 mm (95%
 Bassir et al

Statistics for each study

Difference Lower Upper
Study in means limit limit P value Difference in means and 95% CI
Aimetti et al, 2009 1.200 0.293 2.107 .009
Barone et al, 2008 2.000 1.368 2.632 .000
Barone et al, 2013 2.000 1.670 2.330 .000
Camargo et al, 2000 –0.420 –7.484 6.644 .907
Casado et al, 2010A 3.210 2.609 3.811 .000
Casado et al, 2010B 2.580 2.245 2.915 .000
Casado et al, 2010C 3.060 2.441 3.679 .000
Festa et al, 2013 1.900 1.005 2.795 .000
Goh et al, 2015 –0.510 –2.051 1.031 .517
Hauser et al, 2013A 0.370 –2.267 3.007 .783
Hauser et al, 2013B 0.010 –3.509 3.529 .996
Iasella et al, 2003 1.400 0.003 2.797 .050
Kotsakis et al, 2014A 1.140 0.415 1.865 .002
Kotsakis et al, 2014B 1.270 0.710 1.830 .000
Lekovic et al, 1997 2.600 1.042 4.158 .001
Lekovic et al, 1998 3.250 2.450 4.050 .000
Mayer et al, 2016 0.370 –1.407 2.147 .683
Pelegrine et al, 2010 1.320 0.560 2.080 .001
1.860 1.444 2.276 .000
–10.0 –5.0 0.0 5.0 10.0
a Favors control Favors experimental

Statistics for each study

Difference Lower Upper
Study in means limit limit P value Difference in means and 95% CI
Aimetti et al, 2009 0.700 0.133 1.267 .016
Barone et al, 2008 2.900 2.001 3.799 .000
Barone et al, 2013 1.000 0.588 1.412 .000
Camargo et al, 2000 0.620 –7.015 8.255 .874
Festa et al, 2013 2.500 1.533 3.467 .000
Goh et al, 2015 0.860 –1.665 3.385 .504
Iasella et al, 2003 2.200 0.751 3.649 .003
Lekovic et al, 1997 0.700 0.199 1.201 .006
Lekovic et al, 1998 1.120 0.452 1.788 .001
Madan et al, 2014 3.730 3.413 4.047 .000
Mayer et al, 2016 –0.167 –1.639 1.305 .824
Pelegrine et al, 2010 0.550 0.097 1.003 .017
Rasperini et al, 2010 2.460 –3.071 7.991 .383
Serino et al, 2003 2.100 0.896 3.304 .001
1.549 0.698 2.400 .000
–10.0 –5.0 0.0 5.0 10.0
b Favors control Favors experimental

Fig 2  Meta-analyses for differences in (a) horizontal dimensional changes of alveolar bone and (b) buccal alveolar bone height
dimensional changes between experimental and control groups.

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Statistics for each study

Difference Lower Upper
Study in means limit limit P value Difference in means and 95% CI
Aimetti et al, 2009 0.300 –0.167 0.767 .208
Barone et al, 2008 0.200 –0.432 0.832 .535
Barone et al, 2013 0.700 0.324 1.076 .000
Festa et al, 2013 0.100 –0.630 0.830 .788
Goh et al, 2015 2.310 1.227 3.393 .000
Iasella et al, 2003 0.900 0.299 1.501 .003
Madan et al, 2014 0.630 0.390 0.870 .000
Serino et al, 2003 0.400 –0.266 1.066 .239
0.593 0.314 0.872 .000
–4.0 –2.0 0.0 2.0 4.0
Favors control Favors experimental
a

Statistics for each study

Difference Lower Upper
Study in means limit limit P value Difference in means and 95% CI
Aimetti et al, 2009 0.100 –0.519 0.719 .752
Barone et al, 2008 0.100 –0.461 0.661 .727
Barone et al, 2013 0.700 0.275 1.125 .001
Festa et al, 2013 0.100 –0.548 0.748 .762
Goh et al, 2015 0.790 –0.961 2.541 .377
Iasella et al, 2003 0.700 0.099 1.301 .023
Madan et al, 2014 0.200 –0.059 0.459 .129
Serino et al, 2003 0.700 –0.128 1.528 .098
0.328 0.155 0.502 .000
–4.0 –2.0 0.0 2.0 4.0
Favors control Favors experimental
b
Fig 3   Meta-analyses for differences in (a) mesial and (b) distal alveolar bone height dimensional changes between experimental
and control groups.

CI = 2.23, 3.45) when recombinant human bone mor-
phogenetic protein-2 was utilized, and only 0.24 mm
(95% CI = –1.87, 2.35) when platelet-rich fibrin alone
was used (Appendix Fig 4).
Subgroup analyses also showed that extraction
sockets with damaged walls benefit significantly more
from alveolar ridge preservation compared with intact
extraction sockets (2.88 mm [95% CI = 2.46, 3.30] vs
1.71 mm [95% CI = 1.26, 2.15]; P < .001; Appendix Fig
5). The effects of tooth position, type of arch, and el-
evation of mucoperiosteal flap on the preservation of
horizontal dimensions of alveolar ridge were not sig-
nificant (P > .05).
Meta-regression analyses were conducted to iden-
tify study characteristics that could explain the hetero-
geneity in treatment effects of the primary outcome
variable (Appendix Table 3). The results of meta-re-
gression analyses identified study type (randomized
controlled trial vs non-randomized controlled trial)
and source of funding (reported vs not reported) as
possible sources of heterogeneity between study es-
timates (P < .001; 95% CI = 0.61, 2.04; R2 = 0.50 and
P < .001; 95% CI = 0.65, 2.07; R2 = 0.53, respectively).
The result of meta-regression was not statistically sig-
nificant for study design (split-mouth vs parallel group
design) and follow-up period (P > .05).
Sensitivity Analysis
The sensitivity analyses demonstrated that excluding
non-randomized trials (studies 4, 5, and 11), studies
with split-mouth design (studies 4, 6, 11, and 12), stud-
ies that did not report their source of funding (studies
1 to 3, 5, 6, 8, 9, 11, 12, and 16), studies with less than
4 months follow-up period (studies 1 and 8), or stud-
ies with higher risk of bias (studies 4 to 6, 11, and 14)
did not substantially change the estimates of effect to

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 Bassir et al

Statistics for each study

Difference Lower Upper
Study in means limit limit P value Difference in means and 95% CI
Aimetti et al, 2009 0.200 –0.336 0.736 .465
Barone et al, 2008 2.600 1.697 3.503 .000
Barone et al, 2013 1.100 0.655 1.545 .000
Festa et al, 2013 1.900 0.857 2.943 .000
Iasella et al, 2003 0.400 –0.528 1.328 .398
Madan et al, 2014 1.080 0.727 1.433 .000
1.145 0.583 1.707 .000
–4.0 –2.0 0.0 2.0 4.0
a Favors control Favors experimental

Statistics for each study

Difference Lower Upper
Study in means limit limit P value Difference in means and 95% CI
Aimetti et al, 2009 1.30 –0.31 2.91 .11
Camargo et al, 2000 2.43 –4.68 9.54 .50
Lekovic et al, 1997 1.90 –0.19 3.99 .07
Lekovic et al, 1998 1.87 0.98 2.76 .00
Pelegrine et al, 2010 –0.38 –1.46 0.70 .49
Rasperini et al, 2010 0.16 –3.27 3.59 .93
1.05 –0.02 2.12 .05
–10.0 –5.0 0.0 5.0 10.0
b Favors control Favors experimental

Fig 4   Meta-analyses for differences in (a) lingual alveolar bone height dimensional changes and (b) socket fill between experimental
and control groups.

Statistics for each study

Difference Lower Upper
Study in means limit limit P value Difference in means and 95% CI
Fiorellini et al, 2005A 0.550 –0.501 1.601 .305
Fiorellini et al, 2005B 1.150 0.232 2.068 .014
Jung et al, 2013 1.500 –0.089 3.089 .064
Madan et al, 2014 3.370 2.062 4.678 .000
Pang et al, 2016A 1.390 1.185 1.595 .000
Pang et al, 2016B 0.690 0.472 0.908 .000
Temmerman et al, 2016 2.000 0.896 3.104 .000
1.359 0.845 1.873 .000
–5.0 –2.5 0.0 2.5 5.0
Favors control Favors experimental

Fig 5   Meta-analyses for differences in bone height dimensional changes measured on cone beam computed tomography between
experimental and control groups.

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Bassir et al

Table 2   Results of Subgroup Analyses for Primary Outcome Variable (Horizontal Dimensional
Changes of Alveolar Bone)
Effect size Between-group
Variable Subgroups No. of trials (95% CI), mm P value P value
Type of wound closure Primary closure 10 2.18 (1.64, 2.72) < .001 .033
No primary closure 18 1.44 (1.03, 1.86) < .001
Flap elevation Flap 13 2.08 (1.56, 2.59) < .001 .082
Flapless 5 1.44 (0.95, 1.93) < .001
Grafting material Xenografts 6 2.18 (1.69, 2.66) < .001 .001
Alloplasts 5 0.91 (0.30, 1.52) .003
Allografts 1 1.40 (0.01, 2.80) .050
Autogenous grafts 1 1.32 (0.56, 2.08) .001
No grafts 5 2.72 (1.95, 3.48) < .001
Use of a barrier membrane Membrane 9 2.39 (2.01, 2.77) < .001 .006
No membrane 9 1.19 (0.42, 1.96) .003
Growth factors Rh-BMP2 2 2.84 (2.23, 3.45) < .001 .003
PRF 2 0.24 (–1.87, 2.35) .823
No growth factor 14 1.73 (1.28, 2.18) < .001
Socket morphology Intact 5 1.71 (1.26, 2.15) < .001 < .001
Damaged 3 2.88 (2.46, 3.30) < .001
Mixed 10 1.54 (0.97, 2.10) < .001
Tooth position Anterior 1 1.32 (0.56, 2.08) .001 .13
Posterior 5 1.21 (0.24, 2.17) .014
Mixed 12 2.09 (1.57, 2.61) < .001
Type of arch Maxilla 2 1.27 (0.69, 1.85) < .001 .068
Mandible 0 – –
Mixed 16 1.95 (1.51, 2.40) < .001

the extent that affect the study conclusions, confirm-
ing the robustness of conclusions of the present meta-
analysis (Appendix Table 4).
Publication Bias
No obvious asymmetry was identified in the funnel
plot analyzing horizontal dimensional changes of alve-
olar bone (primary outcome variable; Appendix Fig 6).
In addition, no evidence of publication bias was found
by Egger test (P = .09; 95% CI = –3.50, 0.30) or Begg and
Mazumdar rank correlation test (P = .40; τ = –0.14) for
the primary outcome variable.
DISCUSSION
The present meta-analysis assessed the efficacy of alve-
olar ridge preservation procedures in reducing postex-
traction hard tissue dimensional loss. Also, the effects
of relevant clinical factors that may affect the outcome
of alveolar ridge preservation procedures were ex-
plored. The results of this meta-analysis revealed that
alveolar ridge preservation procedures are effective in
reducing horizontal dimensional loss that occurs after
tooth extraction by 1.86 mm (95% CI = 1.44, 2.28). In
addition, alveolar ridge preservation procedures were
found to be effective in minimizing postextraction ver-
tical dimensional loss measured radiographically on
cone beam computed tomography scans (1.36 mm;
95% CI = 0.84, 1.87) as well as clinically at buccal
(1.55 mm; 95% CI = 0.70, 2.4), mesial (0.59 mm; 95%
CI = 0.31, 0.87), distal (0.33 mm; 95% CI = 0.15, 0.54),
and lingual (1.14 mm; 95% CI = 0.58, 1.71) aspects of
extraction sockets.
The results of the present meta-analysis are in line
with previous meta-analyses that have reported that
although alveolar ridge preservation procedures do
not prevent postextraction hard tissue dimensional
changes, these procedures are effective in reducing
postextraction alveolar bone resorption.10,14,18–20 De-
spite generally similar conclusions, there are variabili-
ties in the reported magnitude of benefit of alveolar
ridge preservation procedures in these studies. The
magnitude of benefit of alveolar ridge preservation

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procedures for postextraction horizontal dimensional
changes in the present study was found to be 1.86
mm (95% CI = 1.44, 2.28; data pooled from 14 stud-
ies), which is very similar to 1.83 mm (95% CI = 2.95,
0.73; data pooled from 7 studies),10 and 1.89 mm (95%
CI = 1.41, 2.36; data pooled from 6 studies)20 mean
differences reported in two meta-analyses. However,
other studies have reported a lower magnitude of
benefit of these procedures for the same variable such
as 1.20 mm (95% CI = –0.04, 2.43; data pooled from 4
studies),19 1.33 mm (95% CI = 0.69, 1.97; data pooled
from 13 studies),18 and 1.52 mm (95% CI = 1.18–1.86;
data pooled from 6 studies).14 A possible explanation
for this variability relates to the variability in the inclu-
sion criteria of these meta-analyses, resulting in inclu-
sion of different numbers and sets of studies in each
meta-analysis.
In this systematic review and meta-analysis, all
study designs with a control or comparison including
RCTs and controlled clinical trials with parallel group or
split-mouth designs were included in order to present
all existing evidence on the effectiveness of alveolar
ridge preservation. Three other meta-analyses in this
topic used a similar approach in the inclusion of the
studies.10,18,19 However, unlike these meta-analyses
that pooled both clinical data and radiographic data
together in the same analysis, the present study per-
formed separate analyses for clinical and radiographic
data. This can be considered as one of the strengths
of the present meta-analyses since it has been shown
that radiographic measurements underestimate alveo-
lar bone dimensional loss compared with intrasurgical
measurements.24–27 Hence, it may not be appropriate
to pool clinical and radiographic data together. In ad-
dition, it should be emphasized that the radiographic
measurements of alveolar ridge dimensions may not
reflect the true ridge dimensions since it is not possible
to differentiate the new bone formation from the re-
maining graft particles on radiographs. Hence, the out-
comes of radiographic analyses should be interpreted
with caution.
A considerable heterogeneity was observed in the
analysis of the primary outcome variable of this study.
One of the main reasons for this heterogeneity is the
broad definition of alveolar ridge preservation, which
includes any surgical procedures with a goal of pre-
serving ridge dimension after tooth extraction. Hence,
these procedures may be performed with or without
use of various grafting materials, with or without use
of resorbable or non-resorbable barrier membranes,
with or without use of growth factors or other biologi-
cally active molecules, or any of these combinations.
Moreover, any of these procedures can be done with
or without raising a flap as well as with or without
achieving a primary closure. Furthermore, studies that
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Bassir et al
focus on investigating the clinical outcome of alveo-
lar ridge preservation procedures may include intact
or damaged extraction sockets in the anterior or pos-
terior maxilla or mandible. Presence of all these vari-
ables results in hundreds of methods of performing
and studying alveolar ridge preservation procedures.
These variabilities introduce a challenge for all system-
atic reviews evaluating the effectiveness of alveolar
ridge procedures, as the clinical studies on this topic
are heterogenous in nature. One option to address this
challenge is to only include the studies that performed
alveolar ridge procedures using one specific biomate-
rial with a particular technique for extraction sites in
the exact same locations and with similar morphology.
This strategy would perhaps reduce the heterogeneity
among the included studies. However, in this scenario,
not only the chance that no studies met the inclusion
criteria are extremely high, but also, it is obviously not
possible to extrapolate the result of such a systematic
review to the other hundreds of methods of perform-
ing alveolar ridge preservation. Hence, in the pres-
ent review, all methods of performing alveolar ridge
preservation were included to simply compare the
outcome of alveolar ridge preservation procedures,
irrespective of how it was performed, with those of
tooth extraction with no intervention in terms of hard
tissue outcomes. Then, subgroup analyses were per-
formed to explore what clinical variables affect the
outcome of alveolar ridge preservation in a positive or
negative way.
The broad definition of alveolar ridge preservation
led to a considerable heterogeneity among included
studies. In the present meta-analysis, I2 statistic tests
demonstrated that I2 was 79.08% for the primary out-
come variable (horizontal dimensional changes of
alveolar bone), and it ranged between 12.81% and
94.56% for the other outcome variables. The I2 statis-
tic tests estimate the percentage of the variability in
effect estimates due to heterogeneity, and it ranges
from 0% to 100% with lower values corresponding
to less heterogeneity. The heterogeneity found in the
present meta-analysis was still within the similar range
of those reported in the other meta-analyses on this
topic.10,14,18–20 In these meta-analyses, the I2 value for
horizontal dimensional changes of alveolar bone was
reported to be 91.37% by MacBeth et al,19 58% by Ioc-
ca et al,14 92% by Willenbacher et al,18 59.3% by Avila-
Ortiz et al,20 and 99.0% by Vignoletti et al.10 It should
be noted that, similar to the present study, a random-
effects model was also used in all mentioned meta-
analyses on this topic due to the presence of significant
heterogeneity among included studies.10,14,18–20
The results of preplanned meta-regression demon-
strated that study type (randomized controlled trials
vs non-randomized controlled trials) and disclosure
The International Journal of Oral & Maxillofacial Implants 991
Bassir et al
of funding source are contributors to the identified
heterogeneity. Randomized controlled trials are in
many cases less likely to be biased compared with
non-randomized controlled trials, as the latter are sus-
ceptible to selection bias.21 A sensitivity analysis was
performed for the primary outcome variable to assess
the effect of excluding non-randomized controlled tri-
als on the outcome of this meta-analysis. When non-
randomized controlled trials were included, there was
a significant difference between alveolar preservation
sites and control sites, which favored alveolar ridge
preservation with the clinical magnitude of 1.86 mm
(P < .001; 95% CI = 1.44, 2.28; heterogeneity I2 = 79.08%;
τ = 0.71). When non-randomized controlled trials were
excluded, still the difference between alveolar pres-
ervation sites and control sites was significant, which
favored alveolar ridge preservation with the clinical
magnitude of 1.52 mm (P < .001; 95% CI = 1.09, 1.94;
heterogeneity I2 = 67.90%; τ = 0.58). Thus, excluding
the four non-randomized controlled trials did substan-
tially change the estimates of effect to the extent that
affect the study conclusions. It is difficult to interpret
the effect of lack of reporting of funding source on the
outcomes of this meta-analysis. It has been argued
that lack of disclosure of funding source may influence
reporting objectivity.28 Interestingly, excluding studies
that did not disclose the funding source in the sensi-
tivity analysis resulted in reduction in the magnitude
of benefit of alveolar ridge preservation procedures
(1.08 mm; 95% CI = 0.66, 1.49). However, it should be
mentioned that excluding studies lacking disclosure of
funding source did not change the overall conclusion
of the present meta-analysis. Nonetheless, more trans-
parency in disclosing the sources of funding of clinical
studies on this topic is necessary.
The results of subgroup analyses revealed several
important findings. It was found that the weighted
benefit of alveolar ridge preservation procedures
was significantly higher when primary closure was
achieved. Two other meta-analyses that assessed the
effect of achieving primary closure on the outcome
of alveolar ridge preservation procedures did not find
any significant effect.10,20 This may be attributable to
the fact that those subgroup analyses included less
than 10 studies; hence, those studies may not have
enough power to detect a true effect. One of the
strengths of the present study is that it met the recom-
mendation of the Cochrane Handbook for Systematic
Reviews of Interventions for having at least 10 stud-
ies in subgroup analyses.21 In addition, the subgroup
analysis demonstrated that extraction sockets with
damaged walls benefit significantly more from alveo-
lar ridge preservation compared with intact extrac-
tion sockets (P < .001). The overall weighted benefit
from the ridge preservation procedure was 2.88 mm
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(95% CI = 2.46, 3.30) for damaged extraction sockets,
and it was 1.71 mm (95% CI = 1.26, 2.15) for intact ex-
traction sockets. This finding stresses the importance
for performing alveolar ridge preservation procedures
for the damaged sockets at the time of extraction. The
subgroup analyses also showed that alveolar ridge
preservation procedures resulted in less desirable out-
comes when performed without barrier membranes as
well as when alloplast grafting materials were used. In
addition, it was found that alveolar ridge preservation
using platelet-rich fibrin alone does not provide any
significant positive benefit in terms of hard tissue hori-
zontal dimensional changes (P = .823). The mean dif-
ference in hard tissue horizontal dimensional changes
between alveolar ridge preservation and control sites
was only 0.24 mm (95% CI = –1.87, 2.35) when alveolar
ridge preservation procedures were performed using
platelet-rich fibrin. It should be noted that this analysis
is based on two included studies that reported data for
application of platelet-rich fibrin for alveolar ridge pres-
ervation. Therefore, future clinical studies are required
to justify clinical benefits of utilization of platelet-rich
fibrin for alveolar ridge preservation procedures.
The present meta-analyses focused on the out-
comes of alveolar ridge preservation procedures in
terms of postextraction hard tissue dimensional loss.
Although minimizing the hard tissue dimensional loss
after tooth extraction is the primary goal of alveolar
ridge preservation procedures, the clinical significance
of this dimensional loss might be varied according to
the position of tooth in the arch. For example, 2-mm
vertical bone loss in the anterior maxilla may result in
a more clinically challenging situation compared with
2-mm vertical bone loss in the posterior maxilla or an-
terior mandible. Accordingly, it is important to also as-
sess end-point clinical outcomes such as the outcome
of implant therapy after these procedures or the need
for further grafting before implant placement as well
as patient-centered outcomes. In addition, it was not
possible in the present study to assess the outcome of
alveolar ridge preservation procedures according to
the position of the teeth because many studies did not
include the detailed information on the position of the
included extraction sockets. The location of teeth may
affect postextraction hard tissue dimensional loss, as
the thickness of buccal bone is varied depending on
the tooth position. Hence, future studies are needed
to compare the effectiveness of alveolar ridge proce-
dures when it is performed for the extraction sockets
in anterior positions with that of posterior positions.
It should be noted that although subgroup analyses
are very informative and provide valuable information
for patient care as well as future research direction,29
these analyses are observational by nature and may
be subject to the limitations of any observational

investigation.21 Direct comparisons of variables of
interest in large clinical trials with broad eligibility
criteria may provide more reliable information about
the effects of treatments.30 For example, although the
subgroup analyses in the present study showed that
the weighted benefit of alveolar ridge preservation
procedures was significantly higher when primary
closure was achieved, the variability among the stud-
ies included in the analysis, such as different types of
socket morphology, location of socket, grafting mate-
rials, and type of membrane, make it difficult to make
a definitive conclusion about the impact of primary
closure on the dimensional changes of alveolar ridge.
In addition, achieving primary closure not only may
have a negative impact on the soft tissue outcomes of
alveolar ridge preservation by altering the location of
mucogingival junction, but also, it may lead to subopti-
mal esthetic outcomes and additional surgical trauma,
which both may affect patient-centered outcomes of
alveolar ridge preservation. Therefore, future compre-
hensive clinical studies are needed to weight the true
advantages and disadvantages of this variable on the
outcomes of alveolar ridge preservation procedures.
It is important to emphasize that the conclusions of
this meta-analysis might be affected by the quality of
the included studies. Risk of bias assessment showed
that five of the included studies in the meta-analysis
of the primary outcome variable had more than two
“No” or “unclear” domains. Although exclusion of these
studies in the sensitivity analysis did not change the
overall conclusion of this meta-analysis, the inclusion
of these studies may be considered as a possible limi-
tation of this study.
CONCLUSIONS
This systematic review and meta-analysis found that
alveolar ridge preservation procedures are effective in
minimizing both horizontal and vertical postextraction
hard tissue dimensional loss. The results of subgroup
analyses demonstrated that use of barrier membranes
improves the clinical magnitude of benefit of these
procedures. It seems that use of alloplast grafting ma-
terials results in less desirable clinical outcomes. In ad-
dition, it was found that damaged extraction sockets
benefit more from alveolar ridge preservation proce-
dures compared to extraction sockets with intact walls.
ACKNOWLEDGMENTS
The expert assistance of Carol Mita, Reference and Education
Services librarian at the Countway Library of Medicine, Harvard
Medical School, with the electronic literature search and Profs
© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Bassir et al
Chung-Cheng Hsieh and Julie Goodman, Department of Epide-
miology, Harvard School of Public Health, for their help in the
statistical analysis are acknowledged. The authors would like
to thank the authors who provided additional information about
specific questions concerning manuscripts that were found as a
part of the systematic review. The authors received no financial
support for this study and report no conflicts of interest related
to this work.
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