J Clin Periodontol 2013; 40: 721727 doi: 10.1111/jcpe.

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Dimensional alterations of extraction sites after different alveolar ridge preservation techniques a volumetric study
Thalmair T, Fickl S, Schneider D, Hinze M, Wachtel H. Dimensional alterations of extraction sites after different alveolar ridge preservation techniques a volumetric study. J Clin Periodontol 2013; 40: 721727. doi: 10.1111/jcpe.12111.

Tobias Thalmair1, Stefan Fickl2, David Schneider4, Marc Hinze1 and Hannes Wachtel1,3
1

Private Institute for Periodontology and Implantology, Munich, Germany; 2Department of Periodontology, Julius-Maximilians University, Wurzburg, Germany; 3Department of Prosthodontics, Dental School, Free University of Berlin, Berlin, Germay; 4Clinic of Fixed and Removable Prosthodontics and Dental Material Science, University of Zurich, Zurich, Switzerland

Abstract Objectives: The aim of this randomized controlled clinical study was to assess soft tissue contour changes after different alveolar ridge preservation procedures. Material and Methods: Following tooth extraction, 30 patients were randomly assigned to the following treatments (Tx) - Tx 1: xenogenic bone substitute (prehydrated collagenated cortico-cancellous porcine bone) and free gingival graft; Tx 2: free gingival graft alone; Tx 3: xenogenic bone substitute; Tx 4: no further treatment (control). Impressions were obtained before tooth extraction (baseline) and 4 months after surgery. Cast models were optically scanned, digitally superimposed and horizontal measurements of the contour alterations between time points were performed using digital imaging analysis. Results: All groups displayed contour shrinkage at the buccal aspect ranging from a mean horizontal reduction of 0.8 0.5 mm (Tx 1) to 2.3 1.1 mm (control). Statistically signicant differences were found between Tx 1 and Tx 4 as well as Tx 2 and Tx 4. A signicant positive inuence of the free gingival graft on the maintenance of the ridge width was recorded (p < 0.001). Conclusion: In this study, alveolar ridge preservation techniques were not able to entirely compensate for alveolar ridge reduction. Covering the orice of the extraction socket with a free gingival tissue graft seems to have the potential to limit but not avoid the post-operative external contour shrinkage based on optical scans.

Key words: alveolar ridge preservation; dimensional alterations; extraction socket; soft tissue punch Accepted for publication 28 March 2013

Marked morphological and dimensional alterations of the alveolar ridge occur after tooth extraction (Cardaropoli et al. 2003, Schropp et al. 2003, Araujo and Lindhe, 2005). Both horizontal and vertical
Conict of interest and source of funding statement: The authors declare that they have no conicts of interest. This study was supported in part by Tecnoss, Torino, Italy.

changes in dimensions are expected in hard tissue as well as soft tissue (Van der Weijden et al. 2009). The resulting dimensional changes have been evaluated by volumetric analysis in a clinical study (Schropp et al. 2003). The loss of volume in the horizontal dimension amounts 57 mm within the rst 12 months. This corresponds with approximately 50% of the original width of the alveolar bone (Schropp et al. 2003). The resorption of the ridge is more pronounced on the buccal than on

the lingual aspect of the extraction socket (Araujo and Lindhe, 2005) and limited to the marginal onethird of the post-extraction site (Araujo et al. 2008). It was suggested that the higher amount of resorption at the buccal aspect is due to the relatively greater proportion of bundle or tooth-derived bone facially that loses its function after tooth extraction and undergoes atrophy (Araujo and Lindhe, 2005). As the buccal wall of the tooth socket is frequently partially or completely

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is the most predictable. Therefore, the aim of this clinical investigation was to evaluate, to which extent a ller or a soft tissue socket seal contributes to ridge preservation.
Materials and Methods

resorbed (Araujo and Lindhe, 2005), consequently a collapse of the buccal soft tissue leads to marked bucco-oral alterations (Schropp et al. 2003). In particular, in the anterior zone the mentioned alterations of the extraction socket can jeopardize the aesthetic outcome of any dental treatment involving tooth extraction. To reduce volumetric changes occurring after tooth extraction, different treatment modalities have been recommended. As implant installation was not able to alter jo et al. biological procedures (Arau 2005, Botticelli et al. 2004), it was suggested that incorporation of biomaterials into a fresh extraction socket could be a suitable technique for socket augmentation with the ability to maintain the ridge dimension to a certain extent (Nevins et al. 2006, Cardaropoli et al. 2005). Several studies have proposed various ridge preservation techniques following tooth extraction including the placement of graft materials and/or the use of occlusive membranes (Camargnola et al. 2003, Lekovic et al. 1998, Lekovic et al. 1997, Cardaropoli et al. 2005) showing that a signicant reduction in alveolar bone resorption could be avoided. However, data obtained from experimental studies showed that incorporation of biomaterials into the extraction socket is not able to diminish the biological process of the buccal bone plate (Fickl et al. 2008a, Fickl et al. 2008b). Techniques to achieve soft tissue closure of extraction sites have been developed, mainly related to immediate implant placement. Jung et al. (2004) introduced the soft tissue punch technique, the extraction socket was lled with a bone substitute and covered with an epithelialized free connective tissue graft. It was proposed that stabilizing the soft tissue architecture with a free gingival graft has benecial effects on minimizing the soft tissue shrinkage (Jung et al. 2004). It was demonstrated that placing a deproteinized bovine bone material (DBBM) into the extraction socket and closing the socket with a free gingival graft was benecial in limiting the volumetric shrinkage (Fickl et al. 2008b, Fickl et al. 2008a). To date, it is still uncertain which alveolar ridge preservation technique

All patients received instructions in oral hygiene and underwent initial periodontal evaluation including professional tooth cleaning with scaling and polishing until full-mouth plaque score and full-mouth bleeding score <20% were reached.
Inter-examiner accuracy control

The research protocol and the consent form of this clinical investigation were approved by the ethical committee of the Julius-Maximilians University, Wuerzburg, Germany (183/11).
Study population

Subjects selected for participating in this prospective clinical study were counselled and written informed consent was obtained prior to the surgical procedure (Helsinki Declaration of 1975 as revised in 2000). The patients were enrolled and treated in a period of time between January 2011 and September 2011. The study population consisted of 30 adult patients (mean age 46.2, range 2472 years, 13 females) requiring treatment of tooth extraction in the anterior zone ranging to the second bicuspid. The reasons for extraction included root fractures, endodontic treatment failures and advanced caries lesions. The following exclusion criteria were applied: (1) Age <18 years. (2) Smoking status of more than 10 cigarettes/day. (3) Presence of relevant medical conditions: Patients with diabetes mellitus, unstable or life-threatening conditions, or requiring antibiotic prophylaxis. Patients with medication of drugs inuencing the bone metabolism were also excluded. (4) Pregnant or lactating women. (5) History of malignancy, radiotherapy, or chemotherapy for malignancy in the past 5 years. (6) History of autoimmune disease. (7) Presence of acute periodontal or periapical pathology. Only teeth with an intact buccal bone plate were included in the study population. The condition of the buccal bone plate was evaluated intra-surgically after tooth extraction. All extraction sites presented a minimum width of 2 mm of keratinized gingival tissue.

All surgical procedures were performed by four operators (H.W., T.T., S.F. and M.H.) in the same clinic (Private Institute for Periodontology and Implantology, Munich, Germany). To control the accuracy and repeatability between surgeons, a calibration meeting was held in Munich (October 2010). Procedures were explained using digital images and surgical videos. Within the discussion at the calibration meeting, it was decided to make a variation to the original approved protocol (two-arm study with Tx 1 and Tx 3) and to add two additional groups (Tx 2 and Tx 4).
Clinical procedure

Before surgery, impressions of the jaws were obtained in a one-step/ two-viscosity technique with polyether impression materials (Permadyne Garant 2:1/Permadyne Penta H; 3M Espe, St. Paul, MN, USA). Following the administration of local anaesthesia, an intra-sulcular incision was performed and the teeth were gently extracted without elevation of a mucoperiosteal ap or compromising the marginal gingiva. Care was taken to produce as little trauma as possible to the bone around the alveolus. If necessary, the teeth were sectioned to allow atraumatic extraction and, more importantly, preservation of all bone walls. In case of deep fractured teeth, when the remaining supragingival tooth structure was insufcient for the use of a forceps, a specic root extraction device with intra-canalicular anchorage (Benex-Extractor, Zepf Medizintechnik GmbH, Seitingen-Oberacht, Germany) was used to avoid trauma to the surrounding tissues. The extraction sockets were carefully curetted to remove granulation tissue. Patients were enrolled sequentially. A randomization list was generated. Randomization envelopes were supplied and numbered sequen-

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Different alveolar ridge preservation techniques

tially containing the treatment allocation according to the randomization list. The extraction sites were randomly assigned to one of the following treatments: Treatment 1 (Tx 1): The extraction socket was treated using the socket seal technique (Jung et al. 2004). The internal marginal gingiva of the extraction socket was deepithelialized with a diamond bur until bleeding was evident. The extraction socket was lled with a xenogenic bone substitute (pre-hydrated collagenated cortico-cancellous porcine bone; mp3 OsteoBiol, Tecnoss, Torino, Italy) to the level of the bone crest. A free gingival graft with a thickness of 3 mm was harvested from the palate/tuberosity and sutured to the marginal gingiva of the extraction socket with several interrupted sutures (Seralene 70, Serag Wiesner, Naila, Germany) (Fig. 1). Treatment 2 (Tx 2): The internal marginal gingiva of the extraction socket was deepithelialized with a diamond bur and a free gingival graft was sutured into the orice of the extraction socket in the same manner as in Tx 1, however, without the use of a ller material. Treatment 3 (Tx 3): The extraction socket was lled with mp3 (OsteoBiol, Tecnoss, Torino, Italy) and secured with a non-resorbable suture material (Gore-Tex CV5, W.L. Gore & Associates, Putzbrunn, Germany) without the use of a gingival graft (Fig. 2). Treatment 4 (Tx 4): The extraction socket remained with its blood clot only (control). Consecutively, a pre-fabricated resin-bonded bridge was xed to the adjacent teeth without any contact of the pontics to the extraction socket with an auto-polymerizing resin material (Clearl Cores; Kuraray, Tokyo, Japan).
Post-surgical protocol

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(a)

(b)

(c)

(d)

Fig. 1. Treatment group 1. (a) after gentile extraction of tooth 21 the buccal wall is intact, (b) a xenogenic bone substitute is applied into the extraction socket, (c) a gingival autograft is sutured to the marginal soft tissue, (d) clinical situation 4 months post-surgically.

Penta H; 3M Espe) were obtained 4 months after tooth extraction.

Evaluation of tissue contour changes

The patients were instructed to rinse with 0.2% chlorhexidine digluconate twice a day for at least 2 weeks (Vaughan and Garnick, 1989). To reduce swelling, Ibuprofen (600 mg) was prescribed (Pearlman et al. 1997). Sutures were removed 7 days after surgery. Polyether impressions (Permadyne Garant 2:1/Permadyne

The analysis of the soft tissue contour changes was performed at the Clinic of Fixed and Removable Prosthodontics and Dental Material Science, University of Zurich, according to previous studies (Fickl et al. 2009, Thoma et al. 2010). Master casts of each patient were made with dental stone (CAM-Base, Dentona AG, Dortmund, Germany) utilizing the pre-extraction and follow-up impressions after 4 months. The cast models were optically scanned and digitized (Iscan D101, Imetric GmbH, Courgenay, Switzerland) creating STL les (Standard Tessellation Language). The STL les of these digital models representing the two treatment time points were imported into a specic software (SMOP, Swissmeda, Zurich, Switzerland) and were superimposed according to the buccal surface of the adjacent teeth using the best-t algorithm. The same software was used to measure the dimensional changes in the relevant buccal alveolar ridge area comparing the contour before tooth extraction and 4 months after therapy (Fig. 3). The area of measurement was dened by a line parallel to the tooth axis in the middle of the

mesial and distal papilla, by the mucogingival line and the most coronal contour line of the alveolar ridge. As the size of this area differed from site due to the difference in tooth/gap size, the mean volume change per area was calculated as a distance in buccal direction (d [mm] = vol [mm3]/area [mm2]) to allow a direct comparison of dimensional changes between the sites. Before the beginning of the evaluation, a calibration exercise was performed to obtain reproducibility for the measurement of the relevant buccal area. This analysis was conducted by two examiners (D.S. and T.T.), one of them was blinded (D.S.).
Statistical analysis

Sample size calculation was performed on the results of previous studies (Fickl et al. 2009, Fickl et al. 2008b) and resulted in seven subjects per group. For the primary outcome variable (mean dimensional change) it was assumed that the true difference between groups would amount to 0.75 mm with a SD of 0.5. The Type I error probability was set at 0.05, the statistical power at 80%. Statistical analysis was performed using a statistical software program (SPSS 20, IBM Corporation, Armonk, NY, USA) by a statistician (M.

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on the mean distance change. Spearman correlation was computed to indicate associations between the mean distance change and variables (age, gender, jaw, jaw location and method of extraction). Fishers exact test was applied to nd associations between two binary variables. KruskalWallis tested the inuence of the surgeons. The level of signicance was set at p < 0.05.
Results

(a)

(b)

All patients completed the study. Thirty patients were included (13 females); eight were smokers. The mean age was 46.2 years, ranging from 24 to 72 years (Table 1 and Appendix S1).
(c) (d)
Qualitative assessment

Fig. 2. Treatment group 3. (a) tooth 14 needs to be extracted, (b) a xenogenic bone substitute is applied into the extraction socket, (c) buccal view and (d) occlusal view at 4 months post-surgically display the contour preservation.

(a)

(b)

Healing of all treatment groups was uneventful. No intra-operative or postoperative complications occurred. Clinically, 1 week after insertion of the gingival graft, all areas were vascularized, some parts were covered with brin and responded by bleeding after removal of the brinoid surface. Necrotic parts or incomplete wound closure were not observed. After 4 months, all free gingival grafts of group Tx 1 and Tx 2 were fully integrated.
Quantitative assessment

(c)

(d)

Fig. 3. Measured area of tissue volume changes. (a) and (b) superimposed images demonstrating volumetric changes between baseline (yellow colour area) and 4 months (green colour area). (c) and (d) buccal and occlusal view of the measured area (region of interest) in blue colour.

Roos) at the Division of Biostatistics, University of Zurich. The primary outcome variable was horizontal soft tissue dimensional change at 4 months after tooth extraction. Descriptive statistics including box plots were used to indicate the mean, median, minimum, maximum values and the standard deviation in each treatment group. KolmogorovSmirnov Test was used to check the cor-

rectness of the normality assumption. Differences in mean distance change between groups were tested by applying one-way analysis of variance (ANOVA) and post hoc Scheffe test. Inuence of bone ller material and soft tissue seal and other variables like age, gender, jaw or tooth type were the secondary outcome variables. Two-way ANOVA was used to identify possible inuence of the bone substitute ller and the soft tissue seal

The results of the dimensional evaluation are displayed in Tables 2 and 3 and Appendix S1. Horizontal contour shrinkage at the buccal aspect during the 4 month healing period was observed in all groups and ranged from 0.8 0.5 mm (Tx 1) to 2.3 1.1 mm (Tx 4/Control). The following dimensional changes occurred according to the treatment option (descriptive data between stages): Treatment 1 (Tx 1): Mean dimensional differences between baseline and the 4 month scan were 0.79 0.5 mm (range: 0.13 to 1.33 mm) buccally. Treatment 2 (Tx 2): Four months after tooth extraction, the following dimensional changes were recorded for the buccal aspect: 0.85 0.6 mm (range: 0.15 to 1.60 mm). Treatment 3 (Tx 3): The mean differences between baseline and the

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Different alveolar ridge preservation techniques

Table 1. Randomization of treatment options per extraction sites Group Number Gender (M/F) Smoker Maxilla (anter/ premol) Mandibula (premol) Reason for tooth extraction (endo/ fract/caries) 5/3/ 4/2/2 3/2/2 3/2/2

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Tx Tx Tx Tx

1 2 3 4

8 8 7 7

3/5 7/1 5/2 3/4

2 1 2 2

7 7 5 5

(4/3) (4/3) (2/3) (2/3)

1 1 2 2

endo, endodontic reason; fract, root fracture; caries, advanced caries lesion. Table 2. Descriptive statistics with measured area (mm2/mm3) and volume changes (mean, minimum and maximum) Group Tx Tx Tx Tx 1 2 3 4 Area (mm2) 22.04 23.46 19.63 19.72 3.70 2.16 1.29 3.35 Vol (mm3) 19.92 24.89 32.89 41.41 3.77 7.68 6.96 15.96 Mean distance (mm) 0.79 0.85 1.45 2.29 0.5 0.6 0.7 1.1 Min/max distance (mm) 0.13 0.15 0.73 1.23 0.17/1.33 0.20/1.60 0.15/2.14 0.26/3.34 0.21 0.19 0.35 0.54

Table 3. Volumetric data describing the distribution according to mean dimensional change Group Tx Tx Tx Tx 1 2 3 4 <0.5 mm 3 2 0.51.0 mm 2 3 2 1.01.5 mm 3 2 2 2 1.52.0 mm 1 2 1 >2.0 mm 1 3

4 month scans were 1.45 0.7 mm (range: 0.73 to 2.14 mm). Treatment 4 (Tx 4): The mean difference of the dimensional contour changes was 2.29 1.1 mm (range: 1.23 to 3.34 mm). The comparison of the groups by unpaired t-tests (one-way ANOVA) resulted in signicant differences in dimensional change between the test groups Tx 1 and Tx 2 compared with control group Tx 4. No other signicant differences were observed between groups (Fig. 4). Two-way ANOVA showed a signicant inuence of the soft tissue socket seal leading to a lower degree in shrinkage (B = 1.05; p < 0.001). The inuence of the ller was estimated to be not signicant (B = 0.42; p = 0.125). The extraction procedure separation of the root, extraction with forceps or with a mechanical device had no inuence on the buccal contour changes. There was no difference in the volume alterations regarding the location of the tooth. No difference was found between teeth located in maxilla or mandibula.

Spearman correlation did not show any signicant association between predictors (age, gender, smoking, jaw, jaw location and method of extraction) and the mean distance difference. KruskalWallis test revealed no statistically signicant difference among the different surgeons (p = 0.964).
Discussion

Indications for ridge preservation are maintaining a stable ridge volume for optimizing functional and aesthetic outcome and simplifying the treatment procedures subsequent to ridge preservation. This study evaluated different techniques for alveolar ridge preservation following tooth extraction, generating sufcient soft tissue volume for the time of implant placement thus simplifying implantation procedures at earlier time points. The use of xenogenic bone substitute, a free gingival graft and the combination of both for alveolar ridge preservation were assessed. Preserving the extraction socket by

the application of a free gingival graft with or without a xenogenic bone substitute reduced post-operative tissue shrinkage to a certain extent. The outcome of this randomized controlled clinical investigation demonstrated that the different alveolar ridge preservation techniques resulted in less contour reduction from the buccal aspect when compared with unassisted socket healing. The ndings of this study can be well compared to previous animal studies using a similar volumetric data analysis. The horizontal contour changes on the buccal aspect, after extraction the socket was lled with DBBM and covered with a free gingival graft, demonstrated 1.5 mm. It was concluded that the application of DBBM seemed to limit the tissue shrinkage (Fickl et al. 2008b). A xenogenic porcine bone substitute was used in this clinical trial, it was investigated as natural scaffold for new bone formation. An almost complete incorporation of the cortico-cancellous particles surrounded by vital bone was observed (Barone et al. 2008). Compared to ridge preservation with a bovine bone substitute, the grafted sites comprised connective tissue including the graft particles and small amounts of newly formed bone (Carmagnola et al. 2003). The results of this study indicate that the free gingival graft for covering the extraction socket revealed statistically signicant superior results in minimizing the buccal contour shrinkage, irrespective of additionally a xenogenic bone substitute was applicated or not. The biological integration of the free gingival graft was successful as no complication regarding graft necrosis could be observed. It can be assumed that the soft tissue cover at the extraction site has the potential to limit the postoperative contour alterations to a certain extent. This is in accordance with the clinical study of Jung et al. (2004), who reported that 3 weeks after surgery, 99.7% of the soft tissue grafts were fully integrated (Jung et al. 2004). Landsberg and Bichacho (1994) stated that due to primary wound closure and the additional mechanical stability of the free autograft, the soft tissue collapse might be avoided to a certain extent. A statistically signicant effect of the

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of this clinical trial did not show a difference in location and type of tooth. The most important clinical impact of alveolar ridge preservation techniques on patient-related outcome should be to optimize implant placement in the correct position and to avoid additional augmentation procedure. However, a statistical signicance favouring one alveolar ridge preservation technique does not necessarily lead to a clinical benet for the patient, unless the whole treatment is simplied or made more successful. There is still a lack of sufcient evidence on implant-related outcome. Only few studies reported on a possible inuence of alveolar ridge preservation on placing implants and need of further augmentation therapies (Serino et al. 2008, Fiorellini et al. 2005). Therefore, the positive inuence of alveolar ridge preservation techniques on patientrelated outcome may be attributed more to achieving enhanced restorative and aesthetic outcomes, as well as better maintenance of healthy periimplant soft tissues (Vignoletti et al. 2012). In conclusion, the present clinical study demonstrates that the investigated alveolar ridge preservation techniques were not able to prevent soft tissue contour alterations entirely after tooth extraction. It appears that complete ridge preservation is not possible with the alveolar ridge preservation techniques evaluated. The use of a free gingival graft covering the extraction socket was benecial for maintaining soft tissue volume. More studies including a higher number of patients or sites are needed to further investigate these ndings.
References
Araujo, M. G., Liljenberg, B. & Lindhe, J. (2010) Dynamics of Bio-Oss Collagen incorporation in fresh extraction wounds: an experimental study in the dog. Clinical Oral Implants Research 21, 5564. Araujo, M. G. & Lindhe, J. (2009) Ridge preservation with the use of Bio-Oss collagen: a 6-month study in the dog. Clinical Oral Implants Research 20, 433440. Araujo, M., Linder, E., Wennstrom, J. & Lindhe, J. (2008) The inuence of Bio-Oss Collagen on healing of an extraction socket: an experimental study in the dog. The International Journal of Periodontics & Restorative Dentistry 28, 123135. Araujo, M. & Lindhe, J. (2005) Dimensional ridge alterations following tooth extraction. An

Fig. 4. Volumetric changes indicated as mean change distance in millimetres.

gingival autograft with respect to the maintenance of the tissue contours at the buccal aspect was found (Landsberg and Bichacho, 1994). Within the limits of this study evaluating the soft tissue contour volume, primary wound closure by means of a free gingival graft to seal the orice of the extraction socket might be more benecial compared to healing by secondary intention. This is contrary to several clinical trials reporting successful treatment outcomes with secondary wound healing (Camargnola et al. 2003, Serino et al. 2003, Serino et al. 2008). Ridge preservation by simply using a xenogenic bone substitute seemed to be more effective than healing by clot alone, but this difference was statistically not signicant in the present investigation. This lack of evidence may be due to the small number of subjects. This nding would be in accordance with several clinical trials indicating a strong evidence that ridge preservation with grafting materials is more effective (Barone et al. 2008, Cardaropoli and Cardaropoli, 2008). However, it was demonstrated that in marginal portions of some sockets bone substitute particles surrounded by granulation tissue occurred (Araujo et al. 2010, Araujo and Lindhe, 2009). According to previous studies showing that the resorption of the alveolar ridge is more pronounced on the buccal than on the lingual aspect of the extraction socket (Araujo and Lindhe, 2005, Schropp et al. 2003), only the buccal soft tissue

compartment of the experimental sites was analysed. This is a limitation of the study. Because measurements were based on master models, no statements can be made as to whether the documented horizontal volume resorption was caused by loss of soft tissue or underlying bone. However, no complete preservation of the outline of the alveolar crest could be assessed in particular at the buccal aspect. The applied technique showed a high reproducibility and an excellent accuracy for measuring volume changes with a measurement error below 10 mm (Mehl et al. 1997, Windisch et al. 2007). This method offers advantages including its noninvasive character, absence of radiation and the fact that it can easily be applied. Currently, there is one shortcoming of the technique because optical scans were performed on study casts in this study. The accuracy of the method is highly inuenced by the accuracy of the impressions and the casts. Another limitation of the study is the small number of patients in each group. Further clinical investigation should be conducted to recruit a larger patient collective to increase the statistical power of clinical investigations. It is generally assumed that the anterior segment of the dentition responded differently than premolar sites to horizontal ridge reduction. This may indicate that anterior sites are more susceptible to ridge alterations than premolar sites. The results

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Supporting Information

Additional Supporting Information may be found in the online version of this article: Appendix S1. Individual data of the 30 patients. The table reports baseline patient characteristics, treatment assignement, surgeon and outcome variables for each patient. The volumetric changes from baseline to 4 months postoperative are expressed in mean, minimum and maximum change distance.
Address: Tobias Thalmair Praxis Dr. Thalmair Kammergasse 10 85354 Freising Germany E-mail: t.thalmair@praxis-thalmair.de

Clinical Relevance

Scientic rational for the study: Effective ridge preservation techniques could reduce the need for ridge augmentation procedures associated with the subsequent implant treatment. Principal ndings: Ridge preservation procedures using an

autogenous free connective tissue graft as a socket seal are able to reduce horizontal ridge alterations in post-extraction sites. Practical implications: In clinical cases where signicant ridge resorption is expected after tooth extraction, the use of a free gingival graft with or without the application of

a bone substitute could provide a relatively simple and inexpensive treatment to limit the contour shrinkage, eventually eliminating later augmentation procedures.

2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd