J Periodontol • August 2008

Alveolar Bone Preservation in Extraction

Sockets Using Non-Resorbable
dPTFE Membranes: A Retrospective
Non-Randomized Study
Oliver Hoffmann,*† Barry K. Bartee,‡ Christian Beaumont,† Adrian Kasaj,§ Giorgio Deli,i
and Gregor-Georg Zafiropoulos†§

Background: The aim of this study was to investigate the

clinical regeneration of extraction sockets using high-density
polytetrafluoroethylene (dPTFE) membranes without the use
of a graft material.
Methods: A total of 276 extraction sockets were evaluated
in 276 subjects (151 males and 125 females; mean age, 50.2
years; age range: 24 to 73 years). After extraction, flaps were

A
lveolar ridge resorpion following
elevated and a dPTFE membrane was placed over the extrac- tooth extraction is a frequently
tion site. The flaps were repositioned and sutured into place. observed phenomenon that may
Primary closure was not obtained over the membranes. The decrease the possibility of placing dental
cemento-enamel junctions of the adjacent teeth were used implants or impair the esthetic results
as reference points. Measurements were taken postextraction after prosthodontic treatment. Although
and 12 months after surgery in the same areas with the help of the degree of bone loss (BL) varies
a stent and were defined as the distance from the reference among individual subjects and between
points to the bone level. Hard tissue biopsies were taken anatomic sites, it is well accepted that as
from 10 representative cases during implant placement 12 much as 40% of the alveolar height and
months after socket preservation. The bone core samples 60% of the alveolar width may be lost in
were submitted for histologic evaluation. A stringent plaque- the first 6 months following extraction.1
control regimen was enforced in all subjects during the 12- Even subtle postextraction BL may
month observation period. have significant clinical effects, particu-
Results: A significant regeneration of the volume of sockets larly in the esthetic zone. With the current
could be noted by histologic evaluation, indicating that the emphasis on esthetic single-tooth re-
newly formed tissue in extraction sites was mainly bone. No in- placement with dental implants, tech-
fluence of gender, smoking, age, or clinical bone level before niques to preserve natural bone and soft
treatment was found on the percentage of bone gain. tissue contours are of great interest to cli-
Conclusion: The use of dPTFE membranes predictably led nicians. Studies showed that BL occurs in
to the preservation of soft and hard tissue in extraction sites. the vertical and horizontal planes, with the
J Periodontol 2008;79:1355-1369. degree of horizontal BL typically exceed-
ing the degree of vertical BL.1,2 In the hori-
KEY WORDS
zontal plane, BL occurs largely at the
Periodontitis; regeneration. expense of the facial cortical plate, in-
creasing the risk for facial soft tissue reces-
sion, especially in the presence of a thin
* Department of Periodontics, Loma Linda University, Loma Linda, CA.
† Blaues Haus, Dental Center, Düsseldorf, Germany. periodontal biotype.2 Interdental BL may
‡
§
Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX.
Department of Operative Dentistry and Periodontology, University of Mainz, Mainz,
lead to the loss of the interdental papilla.3,4
Germany. Although osseointegration of the dental
i Division of Periodontology, Catholic University of the Sacred Heart, Rome, Italy.
implant may be successful, an anterior im-
plant restoration is often judged an es-
thetic success or failure on the basis of
soft tissue appearance.5-7

doi: 10.1902/jop.2008.070502

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Socket Preservation Using dPTFE Membranes Volume 79 • Number 8

Several clinical techniques and a variety of bioma- MATERIALS AND METHODS

terials have been introduced over the years in an effort Study Population
to prevent or reduce postextraction BL. Initially, the A total of 276 sockets of 361 extracted teeth in 276
concept of vital root retention was proposed based subjects (151 males and 125 females; mean age,
on the observation that bone resorption did not occur 50.2 years; age range: 24 to 73 years), who were
around teeth retained as abutments for partial den- scheduled for socket preservation, were evaluated
tures or overdentures, yet edentulous areas in the in this retrospective, non-randomized study (Table 1).
same jaw exhibited severe resorption. This technique The sockets were assigned to one of two groups:
was later abandoned because of soft tissue complica- single sockets, in cases where only one tooth in an
tions associated with the exposed roots.8,9 Using a area was extracted, or side-by-side sockets, in cases
similar concept, techniques for ridge preservation where two neighboring teeth were extracted (Tables
were introduced in the 1980s using hydroxyapatite 2 and 3). One socket form (single or side-by-side)
in the form of root-shaped cones.10,11 Although the was selected per subject. One hundred twenty – four
technique was successful in terms of ridge preserva- (124) subjects smoking 1 to 10 cigarettes per day
tion, problems with soft tissue encapsulation and were categorized as smokers (44.9%; 45 females
the resultant exfoliation of the cones led to the aban- and 79 males; mean age, 49 years; age range: 24
donment of this technique in favor of particulate to 73 years). Subjects who smoked >10 cigarettes
hydroxyapatite materials. Clinical evaluation of these
per day were excluded from the study (Table 1). All
materials again indicated successful outcomes in
subjects were examined and subsequently treated
terms of bone preservation; however, problems such
between January 1999 and December 2005 in the
as particle migration and loss prevented the wide-
private periodontal practice of one of the authors
spread acceptance of the procedure.
(GGZ) in Düsseldorf, Germany. Cases were referred
The advent of guided tissue regeneration mem-
for treatment. The restoration of the augmented areas
branes provided clinicians with a new method to
with fixed partial dentures or dental implants was
potentially modify extraction socket healing. An
planned in collaboration and consultation with the refer-
early study12 using direct measurements between
ring general dentist and the subject at a later time point
the alveolar ridge crest and fixed reference points
during maintenance. Demographic data, medical and
indicated a statistically significant reduction in BL
when using membranes alone or in combination with dental health history, and smoking status were deter-
particulate materials. Membranes evaluated in that mined by questionnaire; the periodontal status was de-
study included non-resorbable and bioabsorbable termined by a comprehensive periodontal examination.
materials with and without particulate augmentation All subjects had a history of chronic periodontitis
materials. with a minimum of four sites with clinical attachment
Current methods to prevent ridge resorption in- levels (CAL) >4 mm, radiographic evidence of alveo-
clude the use of particulate autografts, allografts, al- lar BL, and bleeding on probing (BOP) in at least four
loplasts, xenografts, and membranes manufactured areas.23 All subjects were treated by scaling/root
from various materials, including those that are planing 4 to 6 months before beginning the study
bioabsorbable or non-resorbable, naturally derived and demonstrated good oral hygiene and compliance
or synthetic.13-18 Each of these biomaterials pro- (probing depth [PD]: 5.1 – 0.9 mm; CAL: 6.2 – 1.2
vides certain advantages and disadvantages. Histor- mm; BOP: 12%; and plaque index [PI]: 10%24).
ically, the bioabsorbable and porous synthetic All subjects were informed about the treatment pro-
materials have required primary closure over the cedures and had ‡1 week after the information was
socket, a requirement that increases surgical com- given before the informed consent form was signed.
plexity, reduces the amount of keratinized gingiva, The study was performed according to the Helsinki Dec-
and disrupts the natural architecture of soft tissues laration of 1975, as revised in 1983. Teeth scheduled for
in the area. extraction and socket preservation at the initial exami-
A membrane made of high-density polytetrafluoro- nation were not extracted during the initial periodontal
ethylene (dPTFE), designed specifically for use in therapy. Instead, they were reduced in height to the gin-
socket grafting, which does not require primary clo- gival level and scaled and root planed together with the
sure was described in case reports.19 The successful remaining teeth.The dentitionwas divided into sextants:
use of this material was demonstrated in animal and a) teeth #1 through #5, b) teeth #6 through #11, c)
clinical investigations.20-22 teeth #12 through #16, d) teeth #17 through #21, e)
The aim of the present study was to determine the teeth #22 through #27, and f) teeth #28 through #32.
effectiveness of dPTFE membranes in preserving the Subjects for the present retrospective non-random-
dimensions of extraction sockets during an 8-month ized study were selected according to the following
healing period. criteria: 1) no contraindications for treatment, such

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J Periodontol • August 2008 Hoffmann, Bartee, Beaumont, Kasaj, Deli, Zafiropoulos

Table 1.
Demographic Characteristics of the Study Population (N = 276)

Age (years)

Gender Smoker n % Mean Minimum Maximum

Female No 80 29.0 50.3 31 67

Yes 45 16.3 46.3 24 66
Total 125 45.3 48.9 24 67
Male No 72 26.1 52.0 26 71
Yes 79 28.6 50.6 26 73
Total 151 54.7 51.2 26 73
Total No 152 55.1 51.1 26 71
Yes 124 44.9 49.0 24 73
Total 276 100.0 50.2 24 73

Table 2.
Distribution of the Treated Sockets in the Study Population

Gender (n [%]) Smokers (n [%]) Age (years)

Female Male No Yes Mean (range) Total (n [%])

Maxilla 59 (43.7) 76 (56.3) 79 (58.5) 56 (41.5) 49.98 (26 to 71) 135 (100.0)
Mandible 66 (48.8) 75 (53.2) 73 (51.8) 68 (48.2) 50.38 (24 to 73) 141 (100.0)

Maxilla: anterior 12 (63.2) 7 (36.8) 11 (57.9) 8 (42.1) 48.95 (27 to 71) 19 (100.0)
Mandible: anterior 8 (36.4) 14 (63.6) 13 (59.1) 9 (40.9) 48.73 (29 to 63) 22 (100.0)
Maxilla: posterior 47 (40.5) 69 (59.5) 68 (58.6) 48 (41.4) 50.15 (26 to 69) 116 (100.0)

Mandible: posterior 58 (48.7) 61 (51.3) 60 (50.4) 59 (49.6) 50.69 (24 to 73) 119 (100.0)
Single sockets 88 (46.1) 103 (53.9) 105 (55.0) 86 (45.0) 50.18 (24 to 73) 191 (100.0)
Side-by-side sockets 37 (43.5) 48 (56.5) 47 (55.3) 38 (44.7) 50.20 (26 to 71) 85* (100.0)

Total 125 (45.3) 151 (54.7) 152 (55.1) 124 (44.9) 50.18 (24 to 73) 276 (100.0)
* In the side-by-side socket group, two teeth can be found per evaluated unit, i.e., the 85 sites consist of 170 extraction sockets.

as systemic diseases (e.g., diabetes), pregnancy, the salvageable complications, or rejection of endodontic
use of prescription medications or consumption of treatment by the subject; 6) teeth adjacent to the
recreational drugs; 2) the use of one membrane only extraction sockets had to be free of overhanging or in-
per surgical site; 3) no more than two neighboring ex- sufficient restoration margins; the restorations were
traction sockets; in cases of two neighboring sockets, replaced if insufficient margins were present; 7) third
both had to be in the same sextant; 4) the buccal and molars were excluded; 8) subjects smoking £10 ciga-
lingual/palatal plate of the extraction socket had to be rettes a day were considered smokers. Those smok-
present with a maximum BL of 50% of the vertical di- ing more were excluded from the study and were
mension; however, sockets with BL in the buccal fur- not considered eligible for the treatment described;
cation area were included if one root was covered by 9) subjects who used prescription medication on a
bone and BL did not extend into the apical third of the regular basis were excluded from the study; and 10)
other root; sockets with BL in the lingual furcation area subjects who began using a medication during the
were excluded from the study; 5) reasons for extrac- study period, including the maintenance phase, were
tion were severely increased mobility, caries, fracture, excluded from the final analysis because medications
Class III furcation involvement, endodontically non- may affect the healing process, and the present study

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Socket Preservation Using dPTFE Membranes Volume 79 • Number 8

Table 3. was elevated. No vertical releasing incisions were

made. All surgeries were performed by the same sur-
Distribution of Sockets by Area
geon. Extractions were done using atraumatic tech-
nique, and the socket was curetted carefully and
Region (n [%])
irrigated with sterile saline solution (Figs. 1A, 1B,
Anterior Posterior Total (n [%]) and 2A). The socket preservation was performed us-
ing a non-resorbable dPTFE membrane# alone with-
Single sockets
out the use of any soft or hard tissue grafts (Figs.
Maxilla 16 (16.2) 83 (83.8) 99 (100.0)
1C and 2B). No further steps were taken to secure
Mandible 8 (8.7) 84 (91.3) 92 (100.0)
Total 24 (12.6) 167 (87.4) 191 (100.0) the membrane in place. The flap was repositioned
and sutured in place with interrupted sutures** (Figs.
Side-by-side sockets 1D and 2C). The membrane was left partially exposed
Maxilla 3 (8.3) 33 (91.7) 36 (100.0) during the healing period (Figs. 1D and 2C).
Mandible 14 (28.6) 35 (71.4) 49 (100.0)
Total 17 (20.0) 68 (80.0) 85 (100.0) Medication and Postoperative Care
Total sockets Subjects scheduled for surgery were prescribed anal-
Maxilla 19 (14.1) 116 (85.9) 135 (100.0) gesics†† (100 mg, once daily for 4 days) and a sys-
Mandible 22 (15.6) 119 (84.4) 141 (100.0) temic antibiotic‡‡ (600 mg, once daily for 6 days).
Total 41 (14.9) 235 (85.1) 276 (100.0) Subjects were instructed to start the medication
1 day before surgery.
All subjects rinsed twice daily with 0.1% chlorhex-
idine digluconate solution§§ starting 1 day before sur-
was not designed to standardize or control for a
gery until 1 week after membrane removal.
medication variable.
Sutures were left for 10 days. The membrane was
removed 4 weeks after surgery.
Examiner’s Calibration
All measurements were taken by one periodontist Measurements
who was not the surgeon who performed the proce- The cemento-enamel junction (CEJ) of the adjacent
dures. After initial training of the technique on casts, teeth were used as reference points. The study reports
the examiner was calibrated by repeated measure- only measurements at the same area of the selected
ments of 40 single and 40 side-by-side extraction defect. Measurements were rounded up to the next
sockets on the day of extraction as well as 2 and 4 millimeter.
days thereafter, achieving an intraexaminer reliabil- The examiner who performed the measurements
ity of 90% (data not shown). The examiner was recal- was not the surgeon who provided the surgical treat-
ibrated once a year by measuring 10 extraction ment. The clinical parameters described below were
sockets of each form (single/side-by-side) following assessed using a periodontal probe.ii A stent was fab-
the initial protocol. ricated before the extraction using a cast (Figs. 3A
through 3C). The tooth to be extracted was removed
Clinical Examination from the cast, and two clasps for the adjacent teeth
Prior to the surgical phase, a comprehensive dental were fabricated. The two clasps were connected by
and periodontal examination was completed on all a resin plate that was located approximately at the
subjects. Periodontal evaluation included measuring height of the CEJ of the adjacent teeth. In cases in
PD, CAL, BOP, tooth mobility, furcation involve- which the tooth to be extracted was the most distal
ment, and plaque scores (data not shown). Diagnos- tooth in the sextant, a denture tooth was attached in
tic casts were made and were mounted on a the distal position of the stent to guarantee sufficient
semiadjustable articulator¶ using a face-bow and a stability (Figs. 3B and 3C).
bite registration. Occlusal analysis was performed, di- Markings/holes were made in the following posi-
agnostic wax-ups were prepared on the articulated tions of the resin plate: mesial in the center of the
casts, and restorative treatment needs were deter- stent, distal in the center of the stent, in the direct
mined. center, buccal-mesial, buccal-direct, buccal-distal,
Caries lesions on the neighboring teeth were restored palatal-mesial, palatal-direct, and palatal-distal; the
with composite resin as part of the initial therapy.
¶ SAM-2, SAM Praezisionstechnik, Gauting, Germany.
# Cytoplast, Regentex GBR-200, Oraltronics, Bremen, Germany.
Surgical Procedure ** Ethibond, Excel 3-0, Johnson & Johnson, St.-Stevens-Woluwe, Belgium.
A modification of the technique described by Bartee17 †† Voltaren, Novartis Pharma, Nuremberg, Germany.
‡‡ Clindamycin, Ratiopharm, Ulm/Donautal, Germany.
was used. An intrasulcular incision extending to the §§ Chlorhexamed Fluid, GlaxoSmithKline, Buehl, Germany.
adjacent teeth was made, and a full-thickness flap ii UNC-15, Hu-Friedy, Leimen, Germany.

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J Periodontol • August 2008 Hoffmann, Bartee, Beaumont, Kasaj, Deli, Zafiropoulos

Figure 1.
Surgical procedure, case 1, maxilla. A) Initial radiograph. B) Surgical site after extraction and debridement of the extraction sockets. C) Membrane
placed. D) Flaps repositioned and sutured in place. E) Surgical site immediately after membrane removal. F) Surgical site after membrane removal
(4 weeks after surgery).

Figure 2.
Surgical procedure, case 2, mandible. A) Surgical site after extraction and debridement of the extraction sockets. B) Membrane placed. C) Flaps
repositioned and sutured in place. D) Surgical site immediately after membrane removal. E) Surgical site 8 weeks after membrane removal. F) Surgical
site 8 weeks after membrane removal. After staining with iodide solution, the unchanged position of the mucogingival junction is visible; no loss of
keratinized gingival is noted.

line from buccal-direct to palatal-direct was defined the stent into the same position and bone sounding
as the ‘‘buccal–palatal line.’’ the area with the same periodontal probe¶¶ after deliv-
Measurements were taken during the surgery after ering a local anesthetic (Fig. 3D).
tooth extraction, elevation of the flap, and removal of
any remaining soft tissue.
One year after the initial surgery, measurements
and orthopantomographs were repeated by placing ¶¶ UNC-15, Hu-Friedy.

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Socket Preservation Using dPTFE Membranes Volume 79 • Number 8

newly formed tissue. Additionally, pan-

oramic radiographs were taken at the
12-month follow-up examination.
Implant insertion and/or prosthodon-
tic treatment was performed 14 months
after membrane removal.

Data Analysis
BL measured at mesial, distal, buccal,
palatal, and central sites as well as in
the buccal–palatal direction was de-
scribed in absolute values and percent-
ages. The percentage of BL versus the
baseline clinical bone level (CBL) was
expressed as means and minimal and
maximal losses. The variables describ-
ing BL were reported individually for
all cases reviewed as well as in groups
by factors of interest investigated, i.e.,
socket form, jaw, and region. Bone gain
(BG) in vertical defects was expressed
Figure 3. as means – SD and minimal, maximal,
Fabrication of the stent. A) Cast with stent. B and C) Modified stent for cases with missing and median values.
distal adjacent tooth. D) The stent is placed; taking the measurements. Interval-scaled variables were exam-
ined for their normal distribution with
the Kolmogorov-Smirnov test. Those
Histology that deviated significantly from the normal distribu-
Hard tissue biopsies were taken using a trephine bur## tion were analyzed with non-parametric tests. For
from 10 representative cases during implant placement all others, parametric tests were used.
12 months after socket preservation. At the time of the The independent-samples t test was used to detect
biopsies, clinical conditions at augmented sites in all any effects of gender and smoking on BL in vertical
subjects were similar, and the clinical appearance im- defects. The effects of these two variables on the
plied that the tissue had healed. The bone core samples percentage of BL were established with the Mann-
were submitted for histologic evaluation (Figs. 4A Whitney U test. The Pearson correlation was used to
through 4C). Samples were decalcified, stained with investigate the influence of age on BG in case of ver-
hematoxylin and eosin, and evaluated under a light mi- tical defects.
croscope at ·200 and ·400 magnification (Figs. 4D BL was taken to reflect absolute changes without
and 4E). regard to baseline CBL, whereas the percentage of
BL was considered to show changes versus baseline
Supportive Periodontal Therapy and
CBLs. The effects of the baseline CBL on the mesial,
Prosthodontic Treatment
distal, buccal, and palatal BLs were evaluated with the
During the first 8 weeks after surgery, subjects under-
x2 test, those on the direct center were evaluated with
went maintenance therapy with a dental hygienist
the Kruskal-Wallis test, and those on the buccal–pal-
once a week. Subjects were instructed to rinse with
atal BL were evaluated with the Mann-Whitney U test.
0.1% chlorhexidine digluconate*** once per day.
The effects of CBL on the percentage of BL were an-
After this time, subjects were enrolled in a support-
alyzed with the Kruskal-Wallis test at the mesial,
ive periodontal therapy schedule consisting of regular
distal, buccal, and palatal sites and with the Spearman
recall appointments every 2 months. During the recall
correlation at the direct center and buccal–palatal
appointments, oral hygiene instructions were given,
sites.
BOP and PI was measured, supra- and subgingival de-
Classification tree analysis was performed to shed
bridement was performed, chlorhexidine stains were
light on the effects of the socket form, the jaw, and the
removed, and the teeth were polished. PD was mea-
region as well as BOP, age, gender, and smoking on
sured at 6-month intervals (data not shown); how-
BL and percentage of BL. This served to rank the
ever, no PD measurements were recorded during
the maintenance visits at the teeth neighboring ## Aesculap, Tuttlingen, Germany.
the sockets to prevent any possible damage to the *** Chlorhexamed Fluid, GlaxoSmithKline.

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J Periodontol • August 2008 Hoffmann, Bartee, Beaumont, Kasaj, Deli, Zafiropoulos

Figure 4.
Histologic sampling. A) Site before taking of the histologic sample, flap elevated. B) Trephine bur with sample. C) Retrieved sample. D and E)
Histologic sections of newly formed bone. (Hematoxylin and eosin; original magnification: D, ·200; E, ·400.) F) Radiograph of the sampling area.

considered influencing variables in terms of the ized areas of bone marrow with lymphocytes and,
intensity of their effect and to detect interactions rarely, granulocytes were seen (Figs. 4D and 4E).
between them. Subjects who had undergone previous periodontal
A 5% significance level was defined for all statistical therapy were examined at each supportive periodon-
procedures. All tests were two-tailed. Statistical tal therapy visit during the maintenance phase; none
software††† was used throughout. of the subjects had BOP >8% (range 5% to 8%).
CBL ranged from 3 to 7 mm at mesial, distal, buc-
cal, and palatal sites (Table 4). The baseline CBL in
RESULTS the direct center was 4 to 6.5 mm (mean, 5.1 mm).
The buccal–palatal CBL was 5 to 14 mm (mean, 9.8
A total of 276 sockets (191 single and 85 side-by-
mm) at baseline (Table 4). One year after surgery,
side) in 276 subjects were treated (Tables 1 and 2).
BL was estimated at 0.5 to 2 mm (Table 5).
A total of 135 sockets (49%) were in the maxilla,
No correlation between baseline CBL and BL was
and 141 sockets (51%) were in the mandible (Table 3);
found mesially, distally, buccally, or palatally (x2
44.9% of the subjects treated were smokers (Table 1).
test, P >0.100) in the direct center of the sockets
None of the subjects enrolled in this study reported
(Kruskal-Wallis test, P >0.500) or at the buccal–
any unusual pain or discomfort, abscess, swelling, or al-
palatal site (U test, P >0.500). However, the percent-
lergic reactions during the course of treatment. Mem-
age of BL correlated significantly with the baseline
branes were left partially exposed after surgery. No
bone level (CBL) at all sites (Kruskal-Wallis test,
sign of acute inflammation, exudate, or pain was de-
P <0.001 for the mesial, distal, buccal, and palatal
tected. Plaque accumulation was observed on exposed
data; Spearman correlation coefficient R = -0.514,
surfaces of the membranes. After membrane retrieval,
P <0.001 for the direct center and R = -0.294,
non-epithelialized soft tissue was found in the areas pre-
P <0.001 for the buccal–palatal data). The percentage
viously covered by the membrane (Figs. 1E and 2D).
of BL decreased with increasing baseline BL (CBL) at
This tissue completely reepithelialized clinically within
all sites.
4 weeks after membrane removal (Figs. 1F, 2E, and
A classification tree analysis was used to evaluate the
2F). Nevertheless, a slight but clearly distinguishable
influence of jaw, region, socket form, age, gender, smok-
difference in color compared to the adjacent mucosa
ing, and BOP on BL and percentage of BL. No influ-
persisted (Figs. 1F, 2E, and 2F). Clinically, the whole
ence of age, gender, smoking, or BOP on BL or
keratinized gingiva was preserved.
percentage of BL on the mesial, distal, palatal, buc-
Bone tissue with a regular trabecular structure was
cal, direct center, or buccal–palatal data was present
found histologically. Osteocytes as well as osteoblasts
signaling active bone formation were present. Local- ††† SPSS for Windows 15/2006, SPSS, Chicago, IL.

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Socket Preservation Using dPTFE Membranes Volume 79 • Number 8

Table 4.
CBL at Baseline

CBL (mm) Mesial (n [%]) Distal (n [%]) Buccal (n [%]) Palatal (n [%]) Direct Center (n [%]) Buccal–Palatal (n [%])
1
1.5

2
3 76 (27.5) 68 (24.6)
4 62 (22.5) 97 (35.1) 78 (28.3) 40 (14.5)

4.5 11 (4.0)
5 67 (24.3) 56 (10.3) 84 (30.4) 66 (23.9) 134 (48.6) 2 (0.7)
5.5 23 (8.3)

6 69 (25.0) 74 (26.8) 95 (34.4) 64 (23.2) 67 (24.3) 28 (10.1)

6.5 1 (0.4)
7 78 (28.3) 70 (25.4) 23 (8.3)
8 38 (13.8)

9 27 (9.8)
10 36 (13.0)
11 40 (14.5)

12 59 (21.4)
13 20 (7.2)
14 3 (1.1)

Total 276 (100.0) 276 (100.0) 276 (100.0) 276 (100.0) 276 (100.0) 276 (100.0)
Mean – SD 5.6 – 1.12 5.2 – 1.53 5.0 – 0.84 4.5 – 1.10 5.1 – 0.64 9.8 – 2.24
Minimum 4.0 3.0 4.0 3.0 4.0 5.0

Maximum 7.0 7.0 6.0 6.0 6.5 14.0

Median 6.0 6.0 5.0 4.0 5.0 10.0

Table 5.
Distribution of BL

BL (mm) Mesial (n [%]) Distal (n [%]) Buccal (n [%]) Palatal (n [%]) Direct Center (n [%]) Buccal–Palatal (n [%])
0.0 138 (50.0)
0.5 133 (48.2) 135 (48.9) 136 (49.3) 138 (50.0) 138 (50.0)
1.0 143 (51.8) 141 (51.1) 140 (50.7) 138 (50.0) 175 (63.4)

1.5 62 (22.5)
2.0 39 (14.1)
Total 276 (100.0) 276 (100.0) 276 (100.0) 276 (100.0) 276 (100.0) 276 (100.0)

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J Periodontol • August 2008 Hoffmann, Bartee, Beaumont, Kasaj, Deli, Zafiropoulos

as opposed to the varying influences of jaw, region, the maxilla (classification tree, P = 0.048). Region
and socket form. and socket form had no significant influence on this
BL in the mesial region was significantly influenced measurement (Fig. 6).
by the jaw (maxilla/mandible; classification tree, P = Classification tree analysis for the buccal BL and
0.016), with a higher BL in the mandible (Fig. 5). percentage of BL demonstrated that the socket form
No differences in the mesial percentage of BL could (single versus side-by-side) had the biggest influence
be found in relation to the jaw, region, or socket form. on BL, with a significantly greater BL (classification
No influence of jaw, region, and socket form on the tree, P = 0.004; Padj = 0.008) and percentage of BL
distal BL was present, whereas the distal percentage (classification tree, P = 0.039; Padj = 0.078) in the sin-
of BL in the mandible was significantly lower than in gle sockets. Furthermore, BL and the percentage of
BL in the single sockets
were dependent on the
region. BL (classification
tree, P = 0.004; Padj =
0.008) and the percent-
age of BL (classification
tree, P = 0.047; Padj =
0.094) were significantly
higher in the posterior
region than in the ante-
rior region, although the
difference for the per-
centage of BL was not
significant after a-ad-
justment (Figs. 7 and 8).
The direct center BL
was most affected by
the form of the sockets
Figure 5. (classification tree: P
Influence of the jaw on the absolute BL in the mesial areas. Adj. = adjusted; df = degrees of freedom. <0.001, Padj <0.002 [ab-
solute]; P <0.001, Padj
<0.002 [%]). BL and the
percentage of BL were
significantly greater in
side-by-side sockets
than in single sockets.
The jaw (maxilla/man-
dible) had a significant
effect on single sockets
(classification tree: P
<0.001, Padj <0.002 [ab-
solute]; P = 0.003, Padj =
0.006 [%]). BL and the
percentage of BL were
significantly higher in
the direct center of single
sockets in the mandible
compared to those in
the maxilla. The region
did not have any effect.
The opposite was dem-
onstrated for the side-
Figure 6. by-side sockets with
Influence of the jaw on the relative BL (percentage of BL) in the distal area. Adj. = adjusted; df = degrees regard to the percentage
of freedom. The boundaries of the box are Tukey’s hinges. The length of the box is the interquartile range (IQR)
of BL. In these, the re-
computed from Tukey’s hinges. Values >1.5 IQRs but <3 IQRs from the end of the box are labeled as outliers (O).
gion had a significant

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Socket Preservation Using dPTFE Membranes Volume 79 • Number 8

The socket form, jaw,

and region did not have
any effect on the buc-
cal–palatal BL, although
the region had a signifi-
cant effect on the per-
centage of BL at this
site (classification tree:
P = 0.042, Padj = 0.084).
Significantly more bone
was lost in the anterior
region than in the poste-
rior region (Fig. 11).
Twenty-eight subjects
(10.14%) presented
with vertical defects in
the buccal wall of the
sockets. At this site, 4 to
8.5 mm of bone were
gained (mean BG, 6.0
Figure 7. mm) (Table 7). In these
Absolute BL in the buccal area. Adj. = adjusted; df = degrees of freedom. cases, the vertical de-
fects were clinically filled
to a level equal to the
neighboring buccal root
(Fig. 12).
Gender (independent-
samples t test, P =
0.307), smoking (inde-
pendent-samples t test,
P = 0.429), and age
(Pearson correlation:
R = 0.188, P = 0.338)
did not have any effect
on BG (Table 7).

DISCUSSION
The present private
practice–based, non-
randomized retrospec-
tive study demonstrated
that the use of a dPTFE
membrane allowed for
a significant regenera-
Figure 8. tion of the volume of
Relative BL (percentage of BL) in the buccal area. Adj. = adjusted; df = degrees of freedom. The boundaries of the sockets following tooth
box are Tukey’s hinges. The length of the box is the interquartile range (IQR) computed from Tukey’s hinges. extraction. Histologic
Values >1.5 IQRs but <3 IQRs from the end of the box are labeled as outliers (O). evaluation indicated
that the newly formed
effect (classification tree: P = 0.008, Padj = 0.016 [%]), tissue in the extraction site was mainly regular trabec-
whereas there was no major difference in BL between ular bone with areas of bone marrow and typical cells.
the maxilla and the mandible. The percentage of BL in This tissue is similar to bone found in healed extrac-
the direct center of side-by-side sockets was signifi- tion sites where no grafting procedures were used, in-
cantly higher in the posterior region than in the anterior dicating that normal healing mechanisms were not
region (Figs. 9 and 10; Table 6). impaired.25

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adverse tissue reactions or inflammatory changes

could be observed during the follow-up phase.
A variety of protocols for the preservation of extrac-
tion sockets has been described previously, such as
the use of membranes, grafting materials, or a combi-
nation of both. Although the use of grafting materials
leads to predictable positive outcomes, the long time
necessary for these materials to be replaced by ma-
ture bone is a possible disadvantage.13,25,27
Another option is the use of expanded PTFE
(ePTFE) membranes. A drawback of this material is
the high surface roughness, which facilitates adhesion
of bacteria. Thus, primary closure over the membrane
needs to be achieved to avoid exposure to the oral
environment and resulting bacterial colonization
because the resulting inflammation can impair the
treatment outcome.1,28 Furthermore, the removal of
ePTFE membranes often necessitates a second surgi-
cal procedure. To avoid this, bioabsorbable mem-
branes made from different materials can be used.
However, these require primary closure to avoid pre-
mature degradation, which is often not easily achiev-
able when covering extraction sites. Herein lies a
significant advantage of dPTFE membranes; the
membrane is impenetrable for bacteria because of
its surface characteristics.
Primary coverage over the membrane was not ob-
tained in any case in this study. Irrespective of this
fact, positive treatment outcomes were observed in
all cases. These outcomes corresponded largely to
Figure 9. the ones observed in previous studies1,12,18 with the
Classification trees for absolute BL and relative BL (percentage of BL) use of ePTFE or bioabsorbable membranes as well
in the direct center. Adj. = adjusted; df = degrees of freedom. as grafting materials. Because no primary coverage
is necessary, there is no need for releasing incisions
or additional freeing of the flap, thereby facilitating
Although the absence of a control group is a limita- the surgical procedure and enhancing the esthetic out-
tion of the present study, previous studies1,18,25,26 come by not changing the mucogingival junction. In
suggested that a significant amount of bone loss, up addition, because of the comparatively smooth sur-
to 40% of the alveolar height and 60% of alveolar width, face, dPTFE membranes can usually be removed
takes place after extractions if no steps are taken to without an additional surgical procedure.17,29 A slight
preserve the existing bony architecture. The resulting difference in the tissue color was present in some
facial soft tissue recession and recession of the inter- cases, which could easily be treated by a selective
dental papilla may impair the esthetic outcome or ren- compensatory gingivoplasty.
der the placement of dental implants impossible.2,3,5-7 Although the use of dPTFE membranes allows for
No data exist on the effects of oral health care or the preservation of ridge width and height, the treat-
periodontal disease on the treatment outcome of ment outcome is mainly limited by the architecture
socket-preservation techniques. All subjects in the of the existing bony walls. The newly formed bone
present study received initial periodontal treatment seems to follow this outline, i.e., no or only minimal
before the surgery, and only subjects with good oral bone formation seems to take place exceeding the
hygiene were accepted into the study. For the purpose existing bony walls, as was demonstrated in previous
of this study, BOP and PI measurements were limited studies.1,12 Vertical defects of the buccal wall are an
to the teeth adjacent to the surgical site. No differ- exception to this. In cases in which these defects are
ences could be found between the two groups of ex- entirely limited to the buccal wall, the height of the
traction sites, and BOP and PI did not change proximal bone margins seems to be the determining
significantly throughout the study. No further mea- factor for the degree of possible regeneration. This
surements of these parameters were taken, but no may be due to the fact that the membrane is

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Socket Preservation Using dPTFE Membranes Volume 79 • Number 8

degree of bony regenera-

tion in the direct center of
the side-by-side sockets.
The long span of the area
to augment inevitably
leads to the membrane
collapsing in the middle
region. An option to pre-
vent this, other than
placement of a grafting
material, is the use of ti-
tanium to reinforce the
membranes. This con-
cept is used successfully
with membranes made
Figure 10.
Absolute BL and relative BL (percentage of BL) in the direct center. The boundaries of the box are Tukey’s hinges. of other materials.30
The median is identified by an asterisk. The length of the box is the interquartile range (IQR) computed from Although the bone
Tukey’s hinges. Values more than three IQRs from the end of a box are labeled as extreme (*). Values >1.5 IQRs architecture plays a
but <3 IQRs from the end of the box are labeled as outliers (O). major role in the possi-
ble treatment outcome,
no correlation between
CBL before treatment
and BL after treatment
could be found, indicat-
ing that the bone shrink-
age after extraction is
independent of the ini-
tial bone level.
Contrary to this, the
location of the socket
influenced the possible
outcome. The buccal–
palatal BL was signif-
icantly greater in the
anterior region com-
pared to the posterior re-
gion in the maxilla and
the mandible, whereas
the BL in the direct cen-
Figure 11. ter was greater for side-
Relative BL (percentage of BL) in buccal–palatal direction. Absolute BL is not shown because no influence of jaw,
region, or type of sockets was present. Adj. = adjusted; df = degrees of freedom. by-side sockets in the
posterior region. A sim-
ilar result was found for
the buccal BL in the sin-
supported up to this level because membrane stabil- gle sockets. This may be due to site-specific differ-
ity seems to be a crucial factor for a positive treat- ences in bone architecture and quality.25
ment outcome. Furthermore, the limited gain in Greater absolute bone loss was found for the mesial
vertical height corresponded to a previous study18 measurements in the mandible and for the distal mea-
that demonstrated that only the use of block grafts surements in the maxilla. The relative and absolute
or particular grafts together with membranes or tita- bone loss was greater in the maxilla for the single
nium mesh led to significant gains in bone height. sockets, whereas no difference was found for the
The use of a grafting material may also be helpful in side-by-side sockets. This varies from the findings of
preventing a possible collapse of the membrane, es- another study,18 in which a generally higher degree of
pecially in the less supported middle section of the ex- bone loss in the maxilla was reported, possibly be-
traction socket. The tendency of the membrane to cause no further differentiation between the measure-
collapse in unsupported areas may explain the lesser ments was made previously.

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J Periodontol • August 2008 Hoffmann, Bartee, Beaumont, Kasaj, Deli, Zafiropoulos

Table 6.
Distribution of Percentage of BL

Mesial Distal Buccal Palatal Direct Center Buccal–Palatal

(mean (mean (mean (mean (mean (mean
Socket Jaw Region n [range]) [range]) [range]) [range]) [range]) [range])

Total 276 14.20 16.00 15.51 17.87 24.88 2.74

(7.1 to 25.0) (7.1 to 25.0) (8.3 to 25.0) (8.3 to 33.3) (15.4 to 50.0) (0.0 to 10.0)
Maxilla Total 135 13.66 16.95 15.15 17.80 23.61 3.10
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 50.0) (0.0 to 8.3)
Anterior 19 13.75 19.51 13.60 16.89 19.85 4.19
(7.1 to 20.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 25.0) (16.7 to 25.0) (0.0 to 8.3)
Posterior 116 13.64 16.54 15.41 17.95 24.23 2.93
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 50.0) (0.0 to 8.3)

Mandible Total 141 14.73 15.10 15.85 17.94 26.09 2.40

(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (15.4 to 50.0) (0.0 to 10.0)
Anterior 22 12.57 12.42 14.47 18.11 26.18 3.10
(7.1 to 20.0) (7.1 to 20.0) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 44.4) (0.0 to 10.0)
Posterior 119 15.12 15.59 16.11 17.91 26.07 2.27
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (15.4 to 50.0) (0.0 to 8.3)
Anterior 41 13.12 15.71 14.07 17.54 23.25 3.61
(7.1 to 20.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 44.0) (0.0 to 10.0)
Posterior 235 14.39 16.06 15.76 17.93 25.16 2.59
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (15.4 to 50.0) (0.0 to 8.3)

Single 191 14.19 16.14 16.00 18.03 21.87 2.89

(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (15.4 to 50.0) (0.0 to 8.3)
Maxilla Total 99 13.63 17.08 15.50 18.08 20.56 3.20
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 40.0) (0.0 to 8.3)
Anterior 16 14.10 20.36 13.80 17.34 20.44 4.71
(7.1 to 20.0) (7.1 to 33.3) (8.3 to 25.0) (12.5 to 25.0) (16.7 to 25.0) (0.0 to 8.3)
Posterior 83 13.53 16.45 15.82 18.23 20.58 2.91
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 40.0) (0.0 to 8.3)

Mandible Total 92 14.79 15.14 16.52 17.96 23.28 2.55

(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (15.4 to 50.0) (0.0 to 8.3)
Anterior 8 10.86 12.11 13.75 18.54 20.00 2.91
(7.1 to 20.0) (7.1 to 16.7) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 25.0) (0.0 to 6.3)
Posterior 84 15.17 15.43 16.79 17.91 23.59 2.51
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (15.4 to 50.0) (0.0 to 8.3)
Anterior 24 13.2 17.61 13.79 17.74 20.30 4.11
(7.1 to 20.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 25.0) (0.0 to 8.3)
Posterior 167 14.36 15.93 16.31 18.07 22.10 2.71
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (15.4 to 50.0) (0.0 to 8.3)

Side-by-side 85 14.23 15.69 14.43 17.53 31.64 2.43

(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 50.0) (0.0 to 10.0)
Maxilla Total 36 13.74 16.61 14.21 17.01 32.00 2.84
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 50.0) (0.0 to 8.3)
Anterior 3 11.91 15.00 12.50 14.44 16.67 1.39
(7.1 to 14.3) (8.3 to 20.0) (8.3 to 16.7) (8.3 to 25.0) (16.7 to 16.7) (0.0 to 4.2)
Posterior 33 13.90 16.76 14.37 17.25 33.39 2.97
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (20.0 to 50.0) (0.0 to 8.3)

Mandible Total 49 14.60 15.02 14.59 17.91 31.37 2.13

(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 50.0) (0.0 to 10.0)
Anterior 14 13.54 12.60 14.88 17.86 29.71 3.21
(7.1 to 20.0) (7.1 to 20.0) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 44.4) (0.0 to 10.0)
Posterior 35 15.02 15.98 14.48 17.93 32.03 1.69
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (20.0 to 50.0) (0.0 to 5.6)
Anterior 17 13.25 13.03 14.46 17.26 27.41 2.89
(7.1 to 20.0) (7.1 to 20.0) (8.3 to 25.0) (8.3 to 33.3) (16.7 to 44.4) (0.0 to 10.0)
Posterior 68 14.48 16.36 14.42 17.60 32.69 2.31
(7.1 to 25.0) (7.1 to 33.3) (8.3 to 25.0) (8.3 to 33.3) (20.0 to 50.0) (0.0 to 8.3)

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Socket Preservation Using dPTFE Membranes Volume 79 • Number 8

Table 7.
BG in Vertical Buccal Defects

n Mean (mm) SD (mm) Minimum (mm) Maximum (mm) Median (mm)

Gender (P = 0.307)
Female 14 6.04 1.23 4.0 8.0 6.00
Male 14 6.54 1.31 4.5 8.5 6.25
Smoker (P = 0.429)
Yes 13 6.10 1.19 4.5 8.5 6.0
No 15 6.47 1.36 4.0 8.5 7.0
Total 28 6.29 1.27 4.0 8.5 6.0

Figure 12.
Case with a buccal fenestration. A) Initial radiograph. B) Clinical view, flap elevated. C) Final radiograph after treatment; BG to level of previous
adjacent walls is visible.

A modification from the original technique de- periodontal destruction in the remaining dentition
scribed was implemented.17,28 As opposed to the was of no interest. All subjects with periodontal dis-
original protocol, no grafting material was used. It ease went through periodontal therapy before being
was suggested that the membrane creates space, en- enrolled into the study and were put on a strict main-
abling the formation of a blood clot that then serves as tenance schedule to ensure the absence of active peri-
a matrix for bone formation and allows for bony regen- odontal disease. Because subjects were put on
eration, even in the absence of a grafting material.31 chlorhexidine, plaque levels were not evaluated.
Although it was demonstrated that bony regeneration The results of this study indicated that the use of
is possible with this approach, further studies are nec- dPTFE membranes predictably led to the preserva-
essary to evaluate if the use of a grafting material or a tion of soft and hard tissue in extraction sites. Further
titanium-reinforced membrane enhances the treat- studies are necessary to evaluate if the additional use
ment outcome, especially with regard to the degree of grafting materials leads to an enhancement of the
of vertical augmentation. treatment outcome.
Almost 50% of the study subjects were smokers,
but no difference in treatment outcome could be found ACKNOWLEDGMENTS
between the two groups. This seems to contradict ex- The authors thank Mrs. Ulrike Schulz, consultant for
isting clinical experience that smoking impairs the medical statistics, Institute for Medical Statistics,
outcomes of grafting procedures. Further studies Kronshagen, Germany, for the statistical analysis
are needed to evaluate if this is specific to socket- and Mr. Jürgen Hedderich, Institut für Medizinische
preservation techniques in general or is a result of Informatik und Statistik, University of Kiel, Kiel,
the protocol used. A possible explanation for these Germany, Section of Biometry, Institute for Medical
findings is the limited cigarette consumption of the Informatics and Statistics, for help with the analysis
smokers enrolled in this study. and interpretation of the results. Dr. Barry K. Bartee
CALs were evaluated only in the area of surgery. is a clinical consultant for Osteogenics Biomedical,
Because the aim of the study was to evaluate the out- Lubbock, Texas. Beyond this employer–employee re-
come of the socket-preservation technique and the lationship, Osteogenics Biomedical did not provide any
possible effect on the adjacent teeth, the degree of support, financial or material, to the authors or the

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J Periodontol • August 2008 Hoffmann, Bartee, Beaumont, Kasaj, Deli, Zafiropoulos

subjects reported herein. Drs. Zafiropoulos, Hoffmann, 16. Sclar AG. Strategies for management of single-tooth
Beaumont, Kasaj, and Deli report no conflicts of inter- extraction sites in aesthetic implant therapy. J Oral
Maxillofac Surg 2004;62(9 Suppl. 2):90-105.
est related to this study.
17. Bartee BK. Extraction site grafting for alveolar ridge
preservation. Part 2: Membrane-assisted surgical
technique. J Oral Implantol 2001;27:194-197.
REFERENCES 18. Iasella JM, Greenwell H, Miller RL, et al. Ridge pres-
1. Lekovic V, Camargo PM, Klokkevold PR, et al. Preser- ervation with freeze-dried bone allograft and a colla-
vation of alveolar bone in extraction sockets using gen membrane compared to extraction alone for
bioabsorbable membranes. J Periodontol 1998;69:1044- implant site development: A clinical and histologic
1049. study in humans. J Periodontol 2003;74:990-999.
2. Pietrokovski J, Massler M. Alveolar ridge resorption 19. Bartee BK. The use of high-density polytetrafluoro-
following tooth extraction. J Prosthet Dent 1967;17: ethylene membrane to treat osseous defects: Clinical
21-27. reports. Implant Dent 1995;4:21-26.
3. Choquet V, Hermans M, Adriaenssens P, Daelemans P, 20. Bartee BK, Carr JA. Evaluation of a high-density
Tarnow DP, Malevez C. Clinical and radiographic polytetrafluoroethylene (n-PTFE) membrane as a bar-
evaluation of the papilla level adjacent to single-tooth rier material to facilitate guided bone regeneration in
dental implants. A retrospective study in the maxillary the rat mandible. J Oral Implantol 1995;21:88-95.
anterior region. J Periodontol 2001;72:1364-1371. 21. Crump TB, Rivera-Hidalgo F, Harrison JW, Guo IY.
4. Tarnow DP, Elian N, Fletcher P, et al. Vertical distance Influence of three membrane types on healing of bone
from the crest of bone to the height of the interprox- defects. Oral Surg Oral Med Oral Pathol Oral Radiol
imal papilla between adjacent implants. J Periodontol Endod 1996;82:365-374.
2003;74:1785-1788. 22. Walters SP, Greenwell H, Hill M, Drisko C, Pickman K,
5. Mecall RA, Rosenfeld AL. Influence of residual ridge Scheetz JP. Comparison of porous and non-porous
resorption patterns on implant fixture placement and Teflon membranes plus a xenograft in the treatment
tooth position. 1. Int J Periodontics Restorative Dent of vertical osseous defects: A clinical re-entry study.
1991;11:8-23. J Periodontol 2003;74:1161-1168.
6. Razavi R, Zena RB, Khan Z, Gould AR. Anatomic site 23. American Academy of Periodontology. Parameter on
evaluation of edentulous maxillae for dental implant chronic periodontitis with advanced loss of periodontal
placement. J Prosthodont 1995;4:90-94. support. J Periodontol 2000;71:856-858.
7. Buser D, Martin W, Belser UC. Optimizing esthetics for 24. O’Leary TJ, Drake RB, Naylor JE. The plaque control
implant restorations in the anterior maxilla: Anatomic record. J Periodontol 1972;43:38.
and surgical considerations. Int J Oral Maxillofac 25. Irinakis T. Rationale for socket preservation after
Implants 2004;19(Suppl.):43-61. extraction of a single-rooted tooth when planning for
8. Garver DG, Fenster RK. Vital root retention in humans: future implant placement. J Can Dent Assoc 2006;72:
A final report. J Prosthet Dent 1980;43:368-373. 917-922.
9. von Wowern N, Winther S. Submergence of roots for 26. Johnson K. A study of the dimensional changes occur-
alveolar ridge preservation. A failure (4-year follow-up ring in the maxilla following closed face immediate
study). Int J Oral Surg 1981;10:247-250. denture treatment. Aust Dent J 1969;14:370-376.
10. Quinn JH, Kent JN. Alveolar ridge maintenance with 27. Nevins M, Camelo M, De Paoli S, et al. A study of the
solid nonporous hydroxylapatite root implants. Oral fate of the buccal wall of extraction sockets of teeth
Surg Oral Med Oral Pathol 1984;58:511-521. with prominent roots. Int J Periodontics Restorative
11. Kentros GA, Filler SJ, Rothstein SS. Six month eval- Dent 2006;26:19-29.
uation of particulate Durapatite in extraction sites for 28. Buser D, Bragger U, Lang NP, Nyman S. Regeneration
the preservation of the alveolar ridge. Implantologist and enlargement of jaw bone using guided tissue
1985;3:53-62. regeneration. Clin Oral Implants Res 1990;1:22-32.
12. Lekovic V, Kenny EB, Leinlaender M, King CJ 3rd, 29. Bartee BK. Evaluation of a new polytetrafluoroethy-
Hench LL, Berte JJ. A bone regenerative approach to lene guided tissue regeneration membrane in healing
alveolar ridge maintenance following tooth extrac- extraction sites. Compend Contin Educ Dent 1998;
tion. Report of 10 cases. J Periodontol 1997;68: 19:1256-1258, 1260, 1262-1264.
563-570. 30. McAllister BS, Haghighat K. Bone augmentation tech-
13. Nemcovsky CE, Serfaty V. Alveolar ridge preservation niques. J Periodontol 2007;78:377-396.
following tooth extraction of maxillary anterior teeth. 31. Buser D, Dahlin C, Schenk RK. Localized ridge aug-
Report on 23 consecutive cases. J Periodontol 1996; mentation using guided bone regeneration. In: Dahlin
67:390-395. C, Buser D, Schenk RK, eds. Guided Bone Regenera-
14. Stanley HR, Hall MB, Clark AE, King CJ 3rd, Hench LL, tion in Implant Dentistry. Chicago: Quintessence Pub-
Berte JJ. Using 45S5 bioglass cones as endosseous lishing; 1994:189-233.
ridge maintenance implants to prevent alveolar ridge
resorption: A 5-year evaluation. Int J Oral Maxillofac Correspondence: Dr. Oliver Hoffmann, Department of Peri-
Implants 1997;12:95-105. odontics, School of Dentistry, Loma Linda University, Prince
15. Brugnami F, Then PR, Moroi H, Leone CW. Histologic Hall, Loma Linda, CA 92354. E-mail: o_c_g_hoffmann@
evaluation of human extraction sockets treated with yahoo.com.
demineralized freeze-dried bone allograft (DFDBA)
and cell occlusive membranes. J Periodontol 1996; Submitted September 14, 2007; accepted for publication
67:821-825. December 14, 2007.

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