Received: 12 November 2019 Revised: 14 February 2020 Accepted: 10 March 2020

DOI: 10.1111/cid.12899

ORIGINAL ARTICLE

Hard and soft tissue analysis of alveolar ridge preservation in

esthetic zone using deproteinized bovine bone mineral and a
saddle connective tissue graft: A long-term prospective case series

Gaëlle Botilde DDS, MS1,2 | Paul-Emile Colin MD3 |

Oscar González-Martín DMD, PhD, MSc., Clinical Professor4,5,6 |
Geoffrey Lecloux DDS, MS1,2 | Eric Rompen DDS, MS, PhD, Professor1,2 |
1,2
France Lambert DDS, MS, PhD, Professor

1
Department of Periodontology and Oral
Surgery, Faculty of Medicine, University of Abstract
Liege, Liège, Belgium Aim: Although alveolar ridge preservation (ARP) procedures appear to limit bone
2
Dental Biomaterials Research Unit, University
resorption after dental extraction, long-term outcomes remain limited. The objective
of Liège, Liège, Belgium
3
Department of Radiodiagnostic, Faculty of of this prospective case series was to evaluate the long-term hard and soft tissue
Medicine, University of Liege, Liège, Belgium changes after ARP procedure in the aesthetic area, using deproteinized bovine bone
4
Department of Periodontology, University
mineral (DBBM) and saddle connective tissue graft.
Complutense of Madrid, Madrid, Spain
5
Department of Periodontology, University of
Materials and Methods: Fifteen patients were subjected to ARP and impressions and
Iowa, Iowa, Iowa CT scans were taken at baseline and 3 months. After 5 to 7 years, a secondary long-
6
Private Practice, Gonzalez + Solano Atelier term clinical and radiological analysis was carried out. Horizontal alveolar bone
Dental, Madrid, Spain
changes, soft tissue profiles and implant outcomes were assessed.
Correspondence Results: Although a limited hard and soft tissue remodeling occurred during the first
Dr. France Lambert, Head of clinic,
Department of Periodontology and Oral 3 months after ARP, from 3 months to the long-term evaluation, the alveolar bone
Surgery, Faculty of Medicine, University of dimensions remained stable and the soft tissue profiles significantly increased, in the
Liege, Service de Medecine Dentaire, Domaine
du Sart Tilman Bat B-35, B-4000 Liege, more cervical levels. The implant survival rate after 5 to 7 years yielded 100% and
Belgium. peri-implant bone levels and soft tissue health were good.
Email: [email protected]
Conclusion: Within the limits of the study, the present data confirms the long-term
effectiveness of ARP using DBBM and a saddle connective tissue graft offering sta-
ble hard and soft tissue conditions up to 5 to 7 years.

KEYWORDS

aesthetic, alveolar bone, alveolar bone preservation, dimensional change, extraction socket
management, hard tissue volume, long term, soft tissue profile

1 | I N T RO DU CT I O N the dimensional changes in hard and soft tissues following tooth

extraction, alveolar bone remodeling in the maxilla leads to mean hori-
Despite the technological advances in the field of dentistry, many rea- zontal bone loss of 3.8 mm after 6 months.2,3 The severity of this
sons can lead to tooth loss, such as caries, traumatism, endodontic physiological remodeling depends on several factors such as the tooth
failures, or periodontal causes. Tooth removal procedure results in angulation, the facial bone wall thickness, and other differences in the
dimensional hard and soft tissue shrinkage, mainly in the first 3 months tooth sites anatomy.4-6 The majority of the horizontal resorption was
1
of the healing process. According to systematic reviews, evaluating proven to occur mainly on the buccal aspect of the ridge as thin

Clin Implant Dent Relat Res. 2020;1–10. wileyonlinelibrary.com/journal/cid © 2020 Wiley Periodicals LLC 1
2 BOTILDE ET AL.

buccal plates are tooth-dependent structures.7-10 These dimensional deproteinized bovine bone mineral (DBBM) combined with a saddle
changes can result, especially in the aesthetic area, in functional and connective tissue graft. The primary objective was to describe the
aesthetic discrepancies and compromise implant placement. hard and soft tissue changes from baseline up to a follow-up period
In order to prevent this postextraction bone remodeling, a number of 5 to 7 years. The secondary objectives were the assessment of
of alveolar ridge preservation (ARP) techniques have been described in implant survival, peri-implant bone stability, and soft tissue health.
the literature using various biomaterials including autologous bone, Moreover, long-term aesthetic outcomes based on the Pink Esthetic
bone substitutes (allografts, xenografts, and alloplasts), bioactive agents, Score (PES)22 and patient reported outcomes measures (PROMS)
11
and autologous blood-derived products. Several authors emphasized were investigated.
that ARP procedures can significantly limit the bone and soft tissue
shrinkage after extraction and although they cannot limit completely
the shrinkage, they may be a valid treatment option in order to avoid 2 | M A T E R I A L S A N D M ET H O D S
further bone reconstruction.12-19 Furthermore, in order to compensate
for this expected bone remodeling and improve the aesthetic outcomes, 2.1 | Study population
some authors proposed the use of a saddle connective tissue graft in
combination with the biomaterials.20,21 Patients needing tooth replacement in aesthetic area (tooth 15-25)
Nevertheless, the studies evaluating the efficacy of ARP were were recruited from the Department of Periodontology and Oral
mostly conducted over a follow-up periods running from 12 weeks to Surgery of the University of Liège, Belgium. All the patients included
9 months13,15 and long-term data remains limited. in the study met the following inclusion criteria: good general health
The aim of the present study was to evaluate the long-term (ASA 1,2), absence of/or controlled periodontitis, at least 18 years
radiological and clinical outcomes of an ARP technique using old or with a signed approval document by the parents, and cigarette

F I G U R E 1 Surgical procedure and follow-up. A, Atraumatically tooth extraction. B, After granulation removal, connective tissue graft was
harvested from the palate. C, D, The socket was filled with Bio-Oss and the graft was inserted into split-thickness buccal and palatal pouches to
cover the extraction site. E, 3-month follow-up frontal and F, palatal, view. G, Long-term evaluation frontal, and H, palatal, view. Prosthodontics :
Prof. Amélie Mainjot
BOTILDE ET AL. 3

F I G U R E 2 Methodology for three-dimensional imaging analysis. Horizontal measurements of the alveolar process (ridge) at the three
different levels (−2, −4 and −7 mm) perpendicularly to the vertical reference line (yellow line) and at the three different timelines (baseline,
A;3 months, B; long-term, C)

smoking less than 10 per day. The exclusion criteria were: pregnant 2.3 | Surgical procedure
or breastfeeding females, patients included in another study at the
same time, patients with bone disease or under bone metabolism- The full surgical procedure was reported in previous articles.20,21 In
interfering drugs, patients with a history of head and neck radiother- brief, single extractions in the anterior maxilla (14-24) were performed
apy, and patients presenting dehiscence or fenestration on the bone atraumatically and without flap release. After checking the integrity of
wall of the socket. the buccal and palatal bone plate, a biomaterial (Bio-Oss; Geistlich
Pharma AG, Wolhusen, Switzerland) was placed into the socket. A
connective tissue graft harvested from the palate was inserted and
2.2 | Study design sutured in buccal and palatal split-thickness pouches in order to cover
the socket (Figure 1A-D). Tooth brushing was not recommended at
The present study was designed as a prospective case series. the extraction site for 10 following days and the sutures were
Between September 2009 and September 2011, all patients included removed 10 days after surgery. Prescribed medication consisted in
in the study were subjected to the same ARP technique performed Chlorexidine spray (0.12%) BID, Ibuprofen 600 mg TID according to
by two previously calibrated senior periodontists. Radiographic ana- the needs, and Amoxicillin (500 mg TID) antibiotherapy administrated
lyses (CT scans) as well as impressions were performed at baseline for 5 days.
and 3 months thereafter. In June 2016, all patients were recalled for
a secondary long-term analyses during which impression, intraoral
radiography, and cone beam CT (CBCT) were carried out. Alveolar 2.4 | Follow-up
bone remodeling and soft tissue changes were then evaluated
respectively based on computed axial tomography (CT scans) and Patients were followed at 3 months (Figure 1E,F) and then yearly for
models performed at baseline, 3 months and 5 to 7 years after the regular check-ups. When indicated, implants were placed 4 to
procedure. Moreover, when applicable, implant survival and success 6 months after the ARP. Implants restorations or conventional fixed
rates, peri-implant bone levels and clinical parameters including PES, partial denture (FPD) procedures were performed according to the
plaque index (PI), bleeding on probing (BOP), and pocket depth dentist preference and patient choice. In June 2016, all patients were
(PD) were recorded in June 2016. Finally, PROMs were evaluated recalled for a secondary long-term evaluation (Figure 1G,H).
using VAS questionnaire. This study was performed in full accor-
dance with the declared ethical principles of the World Medical Asso-
ciation Declaration of Helsinki of 1975 (revised in 2008) and the 2.5 | Hard tissue analyses
protocol was approved by the ethical committee of the University of
Liège, Belgium (B707201628853). The study was registered in the In order to evaluate the alveolar bone remodeling overtime, the
clinical trials registry: www.clinicaltrials.gov (NCT03410251). patients were subjected to CT scan (Somaton Emotion; Siemens,
4 BOTILDE ET AL.

TABLE 1 Patient, sites, and implants characteristics Problem with automatically superimposed by the software two by two
the title of part B, must be placed between tabacoo use and teeth. (baseline/3 months and 3 months/long term). For each case, the mea-
A. Patient-related descriptive analyses n = 15 surements were made on a parasagittal section going through the
Age (years) Mean (±SD) 43.4 (±13.3) middle edentulous segment determined on the 3-month CT scan. On
min-max 16.7-62.1 this buccal-palatal section, a vertical reference line was drawn in the
Gender Male 6 (40%) center of the alveolar crest in order to measure the ridge (Figure 2,
Female 9 (60%) yellow line). The horizontal dimensions of the alveolar bone crest
Tobacco use (at the cross-sectional No 9 (60%) were measured perpendicularly to the vertical reference line at the
long-term evaluation) <10c/d 4 (26.7%) three following levels: −2, −4, −7 mm below the most coronal point
of the 3-month section (Figure 2A-C). Thereafter, the same measure-
>10c/d 2 (13.3%)
ments were taken on the baseline CT and long-term CBCT images by
B. Site characteristics n = 15
superimposing the 3D images as well as the reference line which was
Teeth Incisors 9 (60%)
reported exactly at the same place in the different scans thanks to the
Canine 0 (0.0%)
superimposition. Altogether, three measurements were taken at each
Premolar 6 (40%) time point giving a total of nine measurements per patient. Long-term
Rehabilitation Implant 12 (80%) bone dimensional changes (expressed both in percentage and in mm)
FPD 3 (20%) were then calculated both from baseline to 3 months and from
C. Implant characteristics and outcomes n = 12 3 months to the long-term follow-up.
Implant type Straumann BL 10 (83.3%)
Nobel Active 1 (8.3%)
Intralock, MDL (Mini 1 (8.3%)
2.6 | Soft tissue outlines volumetric analyses
Drived- Lock) 2.5 mm
PIa Sites with plaque (%) 6/48 (12.5%) The impression and pouring protocols were standardized. Baseline,

BOP a
Sites with BOP 17/48 (35.4%) 3month and long-term alginate impressions were taken with the
same impression material (CavexColorChange , Cavex Holland BV,
PD (mm)a Mean (±SD) 2.96 (±0.84)
Haarlem, The Netherlands) and using an alginate mixer. The impres-
min-max 2-4.8
sions were poured in plaster within a period of 24 hours. Two differ-
DIB (mm) Mean (±SD) −0.05 (±0.73)
ent operators took the baseline and 3- month impressions while all
min-max −1.2-1.3
long-term impressions were taken by a third single operator. The
Implant survival 12 (100%)
casts were scanned with a 3D laser scanner (D250, 3Shape, Copen-
rates
hagen, Denmark). The .stl files obtained from each model were sub-
BOP, bleeding on probing; DIB, distance between implant shoulder and sequently transferred to a digital shape sampling and processing
first bone to implant contact; FPD, fixed partial denture; PD, pocket depth;
software for re-elaboration of 3D models from the 3D scan data
PI, plaque index.
a
At four aspects around implants (mesial, buccal, palatal, distal). (Studio, Geomagic, Research Triangle Park, North Carolina). For each
patient, baseline and long-term models were superimposed follow-
ing a previously reported protocol.24 Prior to taking the measure-
ments, the baseline model was set as the reference, while the
Munich, Germany) at baseline and at 3 months. For these examina- 3-month and long-term model were set as the test. For each sup-
tions, a slide thickness of 0.6 mm was always used. At the long-term erimposed model, 2D labio-palatal sections were obtained in the
evaluation, for ethical reasons and because of the advances in imaging middle of the extraction area, perpendicular to the alveolar crest.
technologies, a CBCT (Newtom 5G; Sitech, France) was chosen to Subsequently, the linear distance between the preoperative and
reduce radiation dose. CBCT was performed using a reduced field of postoperative soft tissue profiles was measured. These measure-
view to cover the desired area at 0.2 mm voxels according to Garib ments were taken at the top of the crest and were repeated at 2 and
et al23 and a reduced exposure protocol. 4 mm in the apical direction (Figure 3).

2.5.1 | Methodology for 3D imaging analysis 2.7 | Long-term aesthetic outcomes

The measurements were performed by matching and superimposing At the long-term evaluation, the PES as described by Fürhauser et al
baseline and 3-month CT scans as well as long-term CBCT scans, was collected for each patient.22 The contralateral tooth was used as
using three-dimensional (3D) reconstruction software (SyngoVia; Sie- control whenever it was possible; otherwise, PES was calculated
mens). After an adequate calibration, two independent operators based on ideal tooth proportions. The threshold for clinical acceptabil-
made all the measurements (GB and PEC). The scans were ity was set at an arbitrary score of 8 out of 14.25
BOTILDE ET AL. 5

F I G U R E 3 Two dimensional
comparison of the superimposed
models perpendicular to the alveolar
crest (Baseline- 3 months, top;
3 months- long-term, middle;
Baseline- long-term, down)

Additionally, aesthetics from a patient perspective were evaluated recorded. Success was defined according to the criteria of Buser,26
using a VAS questionnaire. The following questions were asked: which are (a) absence of suppuration (recurring peri-implant infection),
1. How satisfied are you with your aesthetic rehabilitation?; 2. Do you (b) absence of persistent complaints like pain, foreign body sensation,
have the feeling that the aesthetic appearance of your rehabilitation and/or dysaesthesia, (c) absence of continuous radiolucency area
has changed overtime? around the implant, (d) absence of implant mobility. Additionally, the
peri-implant bone levels were assessed on periapical radiography
using the parallel technique: the linear distance between the implant
2.8 | Long-term implants outcomes shoulder of the bone level implants and the first bone to implant con-
tact (DIB in mm) was measured at the mesial and distal aspects27
At the long-term evaluation, in patients who benefited from an using the specific software Image J64 (National Institutes of Health,
implant rehabilitation, implant survival, and success rates were Bethesda, Maryland). The health of peri-implant soft tissues was also
6 BOTILDE ET AL.

TABLE 2 Hard and soft tissue remodeling (significant p- value in bold)

3 months- Baseline-
n = 15 Baseline-3 months P-value long term P-value long term P-value
Bucco- Cervical level −2 mm −1.41 (±0.64) <.0001 0.01 (±0.78) .97 −1.40 (±0.86) <.0001
palatal hard tissue Medial level −4 mm −0.76 (±0.36) <.0001 −0.24 (±0.58) .13 −1.00 (±0.69) <.0001
remodeling mm (±SD)
Apical level −7 mm −0.45 (±0.36) .0003 −0.43 (±0.37) .0008 −0.88 (±0.48) <.0001
Buccal soft tissue Cervical level 0 mm −0.6 (±0.97) .032 +0.89 (±1.32) .024 +0.26 (±0.76) .202
remodeling mm (±SD) Medial level −2 mm −0.52 (± 0.58) .004 +0.58 (± 0.97) .036 +0.06 (±0.63) .708
Apical level −4 mm −0.29 (± 0.4) .015 +0.31 (± 0.81) .164 +0.02 (± 0.66) .893

assessed at four sites per implant, including: PI, BOP and PD. For PI patient smoked more than 10 cigarettes per day at the time of the
and BOP, a dichotomous score was given (PI: 0 = no visible plaque, inclusion, but 2 patients started smoking more than 10 cigarettes a
1 = plaque at the soft tissue margin; BOP: 0 = no bleeding, 1 = bleed- day over the follow-up period (Table 1A). Overall, socket management
ing) and PD was measured by means of a periodontal probe procedures were applied in nine incisors and in six premolars sites. To
(CP 15 UNC, Hu-Friedy, Chicago, Illinois) and rounded off to the restore the edentulous spaces, 12 patients received an implant and
nearest millimeter.28 3 were managed by a conventional FPD (Table 1B).

2.9 | Statistical analysis 3.2 | Hard tissue analyses

The results were expressed as means and SD for the continuous vari- The 3D imaging measurements showed high reliability, as inter- and
ables and as frequency tables for the categorical variables. The intraexaminer observations were concordant for all measurements
intraclass correlation coefficient (ICC) was used to test the concor- (ICC mean: 0.98; min: 0.95). The results of measurements are pres-
dance between the two examiners for each measurement, at each ented in Table 2.
timeline and for each measurement level. Statistics were performed The measurements of the horizontal bone remodeling revealed
on the mean of both examiners for each parameter. The evolution of that significant bone loss occurred at the three corono-apical levels
the measures between baseline and 3 months, 3 months and long- only during the early phase after extraction (baseline—3 months).
term and baseline and long-term data was evaluated by a paired Stu- Bone losses of −1.41 mm (P < .0001), −0.76 mm (P < .0001), and
dent t test. The analysis of variance was used to compare the levels. −0.45 mm (P = .0003) were respectively found for −2, −4, and −7
The comparison of the differences between patients with implant and levels. Further losses from 3 months to the long-term follow-up
patients without implant was done by a Student t test. Results were remained below 0.5 mm and were not significant except in the more
considered significant at the 5% critical level (P < .05). The calculations apical region (P = .0008) (Table 2).
were performed using the SAS version 9.4 for windows (SAS Institute,
Cary, North Carolina).
3.3 | Soft tissue volumetric analyses

3 | RESULTS Based on the superimposition of the digitalized impressions per-

formed at baseline, 3 months and 5 to 7 years after the ARP, the data
3.1 | Patient demographics revealed a mild buccal shrinkage of the soft tissue outlines from base-
line to 3 months. From 3 months to the long-term follow-up, a signifi-
In total, 29 subjects met the inclusion criteria and were enrolled in this cant gain in the soft tissue contours was observed buccally at the
study. Of these, nine patients dropped out and did not show up for cervical and medial levels. The resulting variation in soft tissue volume
the secondary long-term analysis, two disagreed to undergo the from baseline to 5 years was not significant for each level. The
CBCT, two had missing data, and one was excluded because a guided detailed results are displayed in Table 2.
bone regeneration was performed in the neighboring site over the
follow-up period. Therefore, 15 subjects (six men and nine women,
mean age: 43.4 [SD ± 13.3], min: 16.7-max: 62.1) were considered in 3.4 | Long-term aesthetic outcomes
this study. The patients were recalled after a mean follow-up of
almost 6 years (mean: 70 months, min: 57.3 months-max: The results of PES are displayed in Table 3. The analysis revealed a
81.6 months). A dropout analysis emphasized that no significant dif- mean PES value of 10.9 (min: 8-max: 14) out of 14 points as a maxi-
ference was found between the dropout and followed patients. No mum22 and 100% of the implants were considered aesthetically
BOTILDE ET AL. 7

TABLE 3 Pink Esthetic Score values

PES Mesial Level soft Soft tissue Alveolar Soft tissue Soft tissue
score papilla Distal papilla tissue margin contour process color texture Total PES
0 0/15 (0%) 1/15 (6.6%) 2/15 (13.3%) 1/15 (6.6%) 0/15 (0%) 0/15 (0%) 1/15 (6.6%) 10.9 (min: 8-max: 14)
1 6/15 (40%) 6/15 (40%) 7/15 (46.6%) 8/15 (53.3%) 1/15 (6.6%) 3/15 (20%) 6/15 (40%)
2 9/15 (60%) 8/15 (53.3%) 6/15 (40%) 6/15 (40%) 14/15 (93.3%) 12/15 (80%) 8/15 (53.3%)

TABLE 4 Patient reported outcomes measures (PROMs) (n = 16) evaluating the possible influence of these treatments on the long-
term aesthetic and implant outcomes are lacking.12,13,16,17 To the best
Did you have the feeling
that the aesthetic of our knowledge, the present report is one of the few studies29
How satisfied are you appearance of your assessing long-term outcomes of alveolar ridge preservation proce-
with the aesthetic of rehabilitation decreases dures and the first study assessing long-term hard tissue changes on
your rehabilitation? overtime?
3D images.
1 = not satisfied 1 = yes, a lot
100 = very satisfied 100 = Not at all
Mean (±SD) 91.3 (±9.15) 92.0 (±9.41) 4.1 | Hard tissue remodeling
Min-max 70-100 70-100

In the present study, the main bone dimensional changes were

acceptable according to the criteria. The PROMs related to aesthetic observed during the first 3 months following the ARP procedure and
satisfaction (see question 1) reached a mean VAS score of 9.13 (min: afterwards they remained stable up to 5 to 7 years. A recent literature
7-max: 10) out of 10 and the one assessing aesthetic stability (see review assessing the hard tissue shrinkage after ARP procedures using
question 2) over time displayed a mean VAS score of 9.20 (min: a xenograft emphasized a mean bucco-palatal bone loss of 1.3 mm
7-max: 10) out of 10. The detailed aesthetic outcomes based on after 3 months.30 Although, the heterogeneity of the extracted tooth
patient opinions are displayed in Table 4. types and of measurements protocols limits the comparison, these
results are in agreement with the present results. Moreover, several
studies describe higher horizontal bone remodeling in the cervical
3.5 | Long-term implant outcomes region and the values decrease progressively towards the apical
level.6,20,31 The present study described a similar outcome from base-
Detailed implant characteristics and outcomes are listed in Table 1C. line to 3 months but interestingly, the pattern is inverted from
All of the 12 implants were osseointegrated at the long-term evalua- 3 months to the long-term follow-up. Indeed, from 3 months to the
tion time point, leading to an implant survival rate of 100%. The mean long-term follow-up, the bone dimensions were found to be very sta-
DIB value calculated on the long-term peri-apical radiographs was ble in the cervical and medial levels while a further horizontal loss
−0.05 mm (SD ± 0.73). Implants demonstrated fairly healthy peri- (0.4 mm) was observed at the apical level. Although significant, this
implant soft tissues. Local plaque deposit was registered in 6 out of additional loss is extremely limited from a clinical point of view. The
48 (12.5%) sites around the implants and BOP was found in 17 out of dimensional stability in the more cervical levels might be related to
48 (35.4%) sites. Finally, the mean PD value was 2.96 mm (SD ± 0.84). the nonresorbable characteristics of the biomaterial used in the proce-
dures.32 The initial remodeling would be the consequence of the buc-
cal bone plate resorption and then33 the nonresorbable or slowly
4 | DISCUSSION resorbable biomaterial placed in the socket would provide the long-
term dimensional stability. The slight resorption observed in the apical
This study demonstrated that extraction socket management combin- region might be related to a physiological remodeling related to facial
ing the use of DBBM and a saddle connective tissue graft limited the growth in absence of biomaterials in this apical region.34 Therefore,
bucco-palatal bone shrinkage in the 3 first months after the ARP the nonremodeling properties of the chosen biomaterial might be of
(1.4 mm in the cervical area) when compared to the mean remodeling capital importance for the long-term stability of ARP. Further compar-
of 3.8 mm described in the literature after extraction alone.3 Thereaf- ative studies would be, however, necessary to confirm this
ter, the hard tissue dimensions remained stable up to 7 years, except hypothesis.
in the most apical region where a fairly low additional loss of 0.4 mm
was observed. Moreover, the connective tissue graft used to compen-
sate for the expected bone remodeling, and insure proper soft tissue 4.2 | Soft tissue remodeling
outlines, was found to be effective in the long term.
According to recent systematic reviews, even though the benefits Looking at the soft tissue outlines, it is interesting to observe a loss of
of ARP procedures are nowadays recognized, follow-up studies volume from baseline to 3 months and a gain from 3 months to the
8 BOTILDE ET AL.

long-term follow-up. This observation might be attributed to two dis- the aesthetic outcomes from a patient's perspective displayed excel-
tinct phenomena. On the one hand, the loss of transgingival support lent results (>9 out of 10). It means that patients were highly satisfied
at the time of extraction and restoration of a transgingival part at with the aesthetic appearance of their implant rehabilitation in the
implant loading may have an influence on the buccal gingival out- long term, which is also an important aspect of success.
lines.35 On the other hand, the tissue creeping after connective tissue The present protocol should also be compared to alternative
graft described by some authors may also be responsible for this gain implant treatment options in the aesthetic zone such as extraction
of volume in the long term.36 However, an impression after the abut- and early or delayed implant placement combined with lateral Guided
ment connection and the restoration of the implant would have been Bone Regeneration (GBR).43,44 This approach was widely described
necessary to accurately assess the effect of these hypotheses. and seems to display short- and long-term effectiveness as well as
hard and soft tissue dimension stability over time.45 However, com-
pared to GBR technique, the advantage of the present protocol is the
4.3 | Implant survival and success absence of flap release and need for a membrane, and therefore
potentially reducing costs and patient morbidity.46 As suggested by
This study demonstrated that single implant placement 4 months after some authors, to further reduce the morbidity, the connective tissue
ridge preservation procedure provides successful long-term outcomes. graft might be performed only if necessary at the time of implant
Indeed, the implant survival rate was 100% and a mean DIB value of placement.47 In this case, at the time of extraction, it might be rele-
−0.05 mm (SD ± 0.73) was found. One of the limitations of this study vant to use a connective or a collagen plug to cover the socket and
is the absence of a standardized x-ray after the implant placement; protect the biomaterials underneath.48
however, the DIB was already proposed by some authors to assess
the peri-implant bone environment.27 These results corroborate the
findings of a recent study demonstrating equal success when implants 4.5 | Study limitations
were placed in preserved vs nonpreserved alveolar ridges.37 Addition-
ally, the peri-implant soft tissue health is considered to be an impor- The present study suffers from several limitations that should be
tant criterion of implant success.38 Comparable PI, BOP, and PD highlighted. First of all, the study was designed as a case series and
values where found in a prospective study on immediate implants does not allow a comparison with another treatment concept. More-
placed in the aesthetic area at 5-year follow-up,28 and these clinical over, the limited samples size and the significant number of dropouts
findings were considered as successful implant outcomes. However, are further weakness of the present study. Although the dropout anal-
better BOP (18.4%) results were found in a 10-year follow-up pro- ysis did not emphasize any significant difference between the dropout
spective study29 on implants placed after ridge preservation using a and followed patients, this limitation should be considered when
xenograft as well. The better BOP described in that study may be interpreting the results.
associated with the strict maintenance care program that patients Finally, from a methodological perspective, the use of two different
received, which indeed may be paramount for long-term implant radiographic methods (CT and CBCTs) may also be critical; however,
success. some authors demonstrated no statistically significant difference in terms
of linear measurements accuracy between CT and CBCT scans.15,49 Addi-
tionally, the use of 3D imaging to evaluate ARP has already been
4.4 | Aesthetic outcomes described in the literature and consists in a well-established method for
the detection of bone dimensional changes.20,30,50
At the long-term follow-up, the PES value reached 10.9 out of Despites these limitations, the study still provides relevant long-
14, which can be considered as a very good score according to some term information on extraction socket management with DDBM and
authors.22,28 Moreover, similar or even a better cervical level of the saddle connective tissue graft.
mucosal margin was found compared to the contralateral tooth, while
mid-facial recession is considered as frequent complication of immedi-
ate implant placement in the aesthetic zone.25,28,39-42 These observa- 5 | CONC LU SION
tions provide some evidence that, in the aesthetic area, socket
management procedure using CTG and delayed implantation could be Despite the limitations of the present study, the management of
more predictable for long-term stability of facial hard and soft tissues. intact extraction socket with DBBM and saddle connective tissue
However, these results have to be interpreted carefully in the absence graft seems to be effective for the preservation of alveolar hard and
of PES baseline values. Moreover, it is important to mention that out soft tissues up to 5-7 years post-treatment. The present long-term
of the 15 patients, 3 were restored with a conventional bridge while study revealed bone dimensional changes only during the 3 first
the PES as described by Fürhauser et al was developed to assess the months after the ARP procedure and stable soft tissue outlines from
aesthetics of implant rehabilitations. baseline up to 5 to 7 years. Additionally, this surgical technique
Although the white esthetic scores (WES) were not considered in allowed implant placement after a follow-up period of 4 to 6 months
the present study as the restorative protocol was not standardized, without any further bone regeneration therapy, as well as long-term
BOTILDE ET AL. 9

implant success rates and aesthetic outcomes. This long-term study 17. Avila-Ortiz G, Chambrone L, Vignoletti F. Effect of alveolar ridge
therefore suggests that this treatment modality is a reliable option for preservation interventions following tooth extraction: a systematic
review and meta-analysis. J Clin Periodontol. 2019;46(Suppl 21):
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