Received: 4 May 2022 Revised: 6 July 2022 Accepted: 26 July 2022

DOI: 10.1002/JPER.22-0213

H UMAN RANDOMIZED CONTROLLED TRIAL

Flap versus flapless alveolar ridge preservation: A clinical

and histological single-blinded, randomized controlled trial

Trever L. Siu1,2 Himabindu Dukka3 Muhammad H. A. Saleh4

Mustafa Tattan5 Ziad Dib3 Andrea Ravidà4,6 Henry Greenwell3
Hom-Lay Wang4 Mauricio G. Araujo7

1 MidwesternUniversity Clinics, Glendale,

Arizona, USA Abstract
2 Private Practice, Avondale, Arizona, Background: The aim of this randomized clinical trial was to compare a flapless
USA technique of alveolar ridge preservation (ARP) to a flap technique to determine
3 Department of Periodontics, University
if preserving the periosteal blood supply would limit loss of crestal ridge width
of Louisville School of Dentistry,
Louisville, Kentucky, USA and height.
4 Department of Periodontics and Oral Methods: Twenty-four patients were randomly assigned to receive ARP using
Medicine, University of Michigan School either a flapless or flap technique. Sockets were grafted with demineralized bone
of Dentistry, Ann Arbor, Michigan, USA
5 Department of Periodontics, College of
matrix and mineralized particulate allograft then covered with a barrier in both
Dentistry, University of Iowa, Iowa City, groups. Re-entry was performed at 4 months to obtain samples for histological
Iowa, USA analysis and subsequent implant placement.
6 Department of Periodontics, Department Results: Ridge width of the flapless group at the crest decreased from 8.3 ± 1.3
of Dentistry, State University of Maringá,
mm to 7.0 ± 1.9 mm for a mean loss of 1.3 ± 0.9 mm (p < 0.05), whereas the
Maringá, Brazil
7 Department of Periodontics & Oral
flap group decreased from 8.5 ± 1.5 mm to 7.5 ± 1.5 mm for a mean loss of 1.0 ±
Medicine, University of Pittsburgh, 1.1 mm (p < 0.05). The mean midbuccal vertical change for the flap group was
Pittsburgh, Pennsylvania, USA a loss of 0.9 ± 1.3 mm (p < 0.05) versus 0.5 ± 0.9 mm (p < 0.05) for the flap-
Correspondence less group. There was no statistically significant difference between the groups.
Hom-Lay Wang, Department of Histologically, flapless ARP revealed more vital mineralized tissue (44 ± 10%)
Periodontics and Oral Medicine,
compared to the flap group (p>0.05). In the flapless group, the occlusal soft tis-
University of Michigan School of
Dentistry, 1011 North University Avenue, sue was significantly thicker than in the flap group at the 4-month re-entry (p<
Ann Arbor, MI 48109-1078, USA. 0.05).
Email: homlay@umich.edu
Conclusions: Crestal ridge width, height, and percentage of vital mineralized
bone following treatment with a flapless ARP technique, was not significantly
different from a flap technique.

KEYWORDS
alveolar ridge augmentation, clinical trial, dental implant, tooth extraction, tooth socket

Trever L. Siu and Himabindu Dukka contributed equally to the manuscript.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Journal of Periodontology published by Wiley Periodicals LLC on behalf of American Academy of Periodontology.

184 wileyonlinelibrary.com/journal/jper J Periodontol. 2023;94:184–192.

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SIU et al. 185

1 INTRODUCTION bone may promote more rapid vascularization of the graft,

resulting in greater formation of vital bone and faster
Alveolar ridge preservation (ARP) is a procedure designed resorption of nonvital/residual graft particles.
to attenuate postextraction osseous ridge dimension
changes. Most studies on postextraction dimensional
changes show that following extraction of single teeth, the 2 MATERIALS AND METHODS
horizontal dimension is most affected by loss, while the
vertical dimension undergoes only slight change.1,2 Extrac- 2.1 Ethical approval and registration
tion studies, in general, show that there is substantial loss
of horizontal ridge width that increases with time. “Thus, This randomized, single-blinded controlled clinical trial
studies with 12-month observational periods demonstrate reports on patients presenting to the Graduate Periodon-
more loss than 6-month follow-up studies, which show tology Clinic at the University of Louisville, Kentucky,
more loss than 4-month follow-up studies.”3–5 and requiring ARP for the purpose of implant place-
Reflection of a mucoperiosteal flap has been shown to ment. This study was conducted in accordance with the
cause loss of crestal alveolar bone.6 These studies were per- Helsinki Declaration for the ethical principles for medical
formed with the tooth present, when the crestal bone had a research involving human subjects, as revised in 2013. The
dual blood supply from both the periosteum as well as the study was approved by the institutional review board (IRB)
periodontal ligament and when it was not possible to deter- of University of Louisville, Kentucky, protocol #047.06.
mine an effect on ridge width.7 Crestal bone loss may have The study was registered at the US National Library of
been at least in part due to the disruption of blood supply Medicine (ClinicalTrials.gov: NCT01901783). The present
derived from the periosteum. The thin nature of the cre- study complies with the Consolidated Standards of Report-
stal bone and its minimal vascular supply make it prone to ing Trials (CONSORT) guidelines.15
resorption leading to loss of crestal width.8 Hence, it may
seem advantageous to avoid flap reflection and preserve
the remaining blood supply from the periosteum. 2.2 Study design and population
However, there is still conflicting evidence regarding sig-
nificant benefit, or lack thereof, associated with a flapless Twenty-four patients participated in this randomized con-
surgical procedure compared to traditional flap reflection trolled, single-blinded clinical trial with two parallel study
as it relates to postextraction bone loss and subsequent groups, conducted at a single center. This study was con-
ARP procedures. Animal studies have not demonstrated ducted at the University of Louisville School of Dentistry,
a significant difference in alveolar bone loss between Department of Periodontics. By random selection, using a
full-thickness flap and flapless or partial thickness flap coin toss, patients were assigned either to the test or control
elevation.9,10 Similarly, no histological or histomorphome- group. Twelve control patients were selected to receive an
tric differences were reported between the flap and flapless intrasocket graft composed of demineralized bone matrix
approaches for tooth extraction and socket grafting pro- allograft* mixed with a corticocancellous mineralized par-
cedures in humans.11 In contrast, in a human study by ticulate allograft† and covered by a calcium sulfate barrier‡
Barone et al. and a canine model by Fickl et al., it was using a full-thickness flap technique. Twelve test patients
shown that more bone resorption occurred with a full- received the same intrasocket allograft mixture covered by
thickness flap in postextraction sockets.12,13 As indicated a calcium sulfate barrier using a flapless technique. All
by the recent systematic reviews, there is a need for clinical clinicians and examiners participating in the trial were
studies investigating ARP that allow for direct comparison calibrated before the surgeries and the measurements.
between surgical variables, such as flap reflection, among
others.3,14
Hence, the primary aim of this randomized controlled 2.3 Inclusion criteria
single-blinded clinical trial was to compare a flapless tech-
nique of ARP versus a conventional flap technique. We The following inclusion criteria were applied: (1) had
hypothesize that preserving the periosteal blood supply one nonmolar tooth treatment planned for extraction and
may minimize loss of crestal ridge width and height. replacement with a dental implant where at least one adja-
As a secondary objective, the histological composition
of the newly formed bone that occupies the extraction
socket was evaluated to determine vital bone percentage. * GraftonMatrix Plug, BioHorizons, Birmingham, Alabama.
It was hypothesized that the increased vascularity pro- † MinerOss, BioHorizons, Birmingham, Alabama.
vided by the intact periosteum lining the facial and lingual ‡ CalForma, Lifecore Biomedical, Inc., Chaska, Minnesota.
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186 SIU et al.

cent tooth was present and (2) the study subjects were at 0.12% chlorhexidine gluconate rinse twice daily, and anal-
least 18 years old and had signed an informed consent. gesics as needed. Patients also received detailed oral
hygiene instructions.
At 4 months post surgery, a 2.7×6-mm trephine core was
2.4 Exclusion criteria taken from the center of the grafted socket immediately
prior to implant placement. The core was placed in 10%
The following exclusion criteria were applied: (1) had a buffered formalin and submitted for histological prepara-
debilitating systemic disease or a disease that affected the tion. The osteotomy site was then fully prepared and a
periodontium, (2) had an allergy to any material or medica- dental implant placed.
tion used in the study, (3) required prophylactic antibiotics,
(4) had previous head and neck radiation therapy, (5) had
chemotherapy in the previous 12 months, (6) were taking 2.6 Outcome measurements
long term nonsteroidal anti-inflammatory drugs or steroid
therapy, and (7) smoked more than one pack of cigarettes 2.6.1 Clinical indices and parameters
per day.
Each patient received a diagnostic work-up including
standardized periapical radiographs, study models, clin-
2.5 Surgical treatment ical photographs, and a clinical examination to record
attachment level, probing depth, recession, and mobility of
For the flap group, a papilla preservation incision was uti- teeth adjacent to the extraction sites. A customized acrylic
lized to raise a full-thickness mucoperiosteal flap on the occlusal stent was fabricated on the study models to serve
facial and palatal/lingual bone to expose the alveolar ridge as a fixed reference guide for the vertical measurements.12
(Figure 1a-A, B). The flap was reflected past the mucogin- Presurgical baseline data consisting of measurements on
gival junction, beyond 5 mm from the crest. Teeth were the site to be treated included: (1) keratinized tissue and (2)
elevated and extracted with periotomes, elevators, and for- soft tissue thickness measured using the dedicated tissue
ceps. For the flapless group, the same extraction technique thickness meter** .16–18
was utilized without flap reflection (Figure 1b, A, B). The After tooth extraction, the following measurements
extraction socket was then curetted to remove all granula- were recorded: (1) horizontal ridge width at the crest and
tion tissue. Both the demineralized bone matrix and the 5 mm apical to the crest using a digital caliper†† and
mineralized corticocancellous particulate allograft were (2) vertical height of the ridge relative to an acrylic stent
hydrated in sterile water for about 10 minutes. For both customized to fit on neighboring teeth.12 All height mea-
the flap and flapless groups, 0.5 cc of mineralized partic- surements were done at midbuccal, midlingual, mesial,
ulate allograft was thoroughly mixed with one package of and distal; all of them were measured at the crest using a
demineralized bone matrix. The mixture was placed into custom stent (Figure 2). For the flapless group, a 2-mm soft
the socket to the level of the socket crest. A crisscross tissue plug was removed at the ridge crest using a trephine
suture was placed over the bone graft in both groups to to create access for the digital caliper. The measurement 5
provide retention for the calcium sulfate barrier. The cal- mm apical to the crest was not performed for the flapless
cium sulfate barrier was mixed and placed over the bone group.
graft and was contained by the buccal and palatal/lingual At 4 months, another standardized radiograph was
flaps. A second crisscross suture was placed over the bar- taken. All baseline indices and measurements were
rier after it had completely set. In the flap group, the repeated. A blinded examiner performed all clinical mea-
flaps were replaced and sutured with 5-0 monofilament surements for both the initial and final data collection
polyglyconate sutures§ . At 4 months, papilla preservation points.
incisions were utilized, and a full-thickness flap was ele-
vated for both the flap and flapless groups. Core biopsies
were taken using trephine burs. Following that, osteotomy 2.6.2 Histological analysis
for implant placement was performed according to the
manufacturer recommendation and implants were placed. Trephine cores (2.7×6 mm) were decalcified, sectioned,
Each patient received a postsurgical regimen of oral and prepared for histological analysis using hematoxylin
antibiotics (doxycycline hyclate 50 mg daily for 2 weeks),
anti-inflammatories (naproxen sodium 375 mg for 1 week), ** SDM gingival thickness meter, Austenal Medizintechnik, Cologne,

Germany.
§ Maxon, Kendall Healthcare, Mansfield, Massachusetts. †† Mitutoyo, Tokyo, Japan.
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SIU et al. 187

F I G U R E 1 (a, Left) Flap procedure. (A) Tooth site before extraction showing a premolar with vertical root fracture. (B) Trapezoidal
papilla preservation incisions buccally and lingually. (C) Tooth was extracted, and mineralized particulate allograft plus demineralized bone
matrix was packed to the bone crest. (D) Crisscross sutures placed over the bone graft in both groups to provide retention for the calcium
sulfate barrier. (E, F) Healed site 4 months after ARP. (G) Trapezoidal papilla preservation incisions buccally and lingually to facilitate clinical
measurements. (H) A tissue-level implant placed in a single stage approach. (I, J) Pre- and post-periapical radiographs. (b, Right) Flapless
procedure. (A, B) Tooth site before extraction. (C) Tooth was extracted, and mineralized particulate allograft plus demineralized bone matrix
was packed filling the socket to the bone crest. (D) Crisscross sutures placed over the bone graft in both groups to provide retention for the
calcium sulfate barrier. (E, F) Healed site 4 months after ARP. (G) Trapezoidal papilla preservation incisions buccally and lingually. (H)
Horizontal ridge width demonstrated clinically after 4 months (note that the measurements were taken using a digital caliper). (I) Implant
placement showing adequate buccal bone. (J) Pre- and post-periapical radiographs. ARP, alveolar ridge preservation

and eosin staining. Twelve- to 15-step serial sections were 2.7 Data analysis
taken from the center of each longitudinally sectioned
trephine core. Six randomly selected fields, one per slide, Means and standard deviations were calculated for all
if possible, were used to obtain percentage of vital bone, parameters. The data were analyzed using a paired t test
remaining graft particles, and trabecular space using a light to determine the statistical significance of the differences
microscope‡‡ at 150×, with a 10× objective and Nikon 15× between baseline and follow-up data, and an unpaired t
reticle eyepieces§§ . test was used to evaluate statistical differences between
the test and control groups. A predetermined sample size
‡‡ American Optics light microscope, New York. of 12 gave 83% statistical power to detect a difference of
§§ Nikon, Tokyo, Japan. 1-mm ridge width between the groups with a standard
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188 SIU et al.

TA B L E 1 Clinical indices for flap and flapless sites (mean ± SD)

Baseline 4 months Change
(index (index (index
units) units) units)
Mean plaque Flap 0.1 ± 0.2 0.2 ± 0.2 −0.1 ± 0.2
index Flapless 0.1 ± 0.2 0.0 ± 0.1 0.1 ± 0.2
Mean gingival Flap 0.1 ± 0.1 0.0 ± 0.0 0.1 ± 0.1
index Flapless 0.1 ± 0.2 0.0 ± 0.1 0.1 ± 0.2
Mean bleeding on Flap 0.2 ± 0.2 0.1 ± 0.2 0.1 ± 0.3
probing Flapless 0.2 ± 0.3 0.1 ± 0.2 0.1 ± 0.2

was delayed at two sites in the flap group; one site needed
sinus augmentation prior to implant placement, while the
other required restorative work on adjacent teeth prior to
implant placement, and placement was delayed by 4 and 1
months, respectively.

3.2 Alveolar ridge width at the crest

Flap cases had a mean initial width at the crest of 8.5 ± 1.5
mm, which decreased to 7.5 ± 1.5 mm at the 4-month re-
entry for a mean loss of 1.0 ± 1.1 mm (p< 0.05, Table 2).
F I G U R E 2 Custom surgical stent fabricated before each case. Flapless cases presented with a mean initial width at the
Channels in these stents guide the North Carolina periodontal crest of 8.3 ± 1.3 mm, which decreased to 7.0 ± 1.9 mm at
probe placement for intrasurgical and re-entry measurements the 4-month re-entry for a mean loss of 1.3 ± 1.0 mm (p<
0.05). There were no statistically significant differences
deviation of 0.8 mm. The mean and standard deviation between the flap and flapless groups (p > 0.05, Table 2a).
used for the power calculation was based on data from
previous studies.19,20 The histomorphometric analysis was
performed using an independent t test. In all tests, sta- 3.3 Alveolar ridge width 5 mm apical to
tistical significance was set at a P value of .05. All data the crest
analyses were conducted using a commercially available
software*** . Flap cases presented with a mean loss of 0.6 ± 1.0 mm (p
> 0.05). For the flapless group, there were no ridge width
measurements 5 mm apical to the crest at baseline. At the
3 RESULTS 4-month re-entry, the flap and flapless cases had a similar
mean width of 8.6 ± 1.4 mm and 8.0 ± 1.6 mm, respectively.
3.1 Sample characteristics There were no statistically significant differences between
the flap and flapless groups at 5 mm apical to the crest (p
A total of 16 females and 8 males with a mean age of > 0.05, Table 2a).
55.0 ± 14.4 years, ranging from 26 to 78 years, were
enrolled. Patients were equally distributed between the
two study groups, with 12 patients per group and no 3.4 Changes in vertical ridge height
dropouts. Recruitment stopped after required sample size
was reached in both groups. No difference was noted Over a period of 4 months, the flap group showed a statisti-
in terms of early postoperative healing between the two cally significant decrease in the mean facial height of 0.9 ±
groups (Table 1), and implants were successfully placed at 1.3 mm (p< 0.05). In the flapless group, there was a statisti-
all treated sites for the flapless group. Implant placement cally significant mean loss of facial height of 0.5 ± 0.9 mm
(p < 0.05). There were no statistically significant differ-
*** Microsoft
Excel for Windows version 16.0, Microsoft Corporation,
ences between groups in terms of vertical change (p> 0.05).
Redmond, Washington. Vertical ridge height changes are reported in Table 2b.
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SIU et al. 189

TA B L E 2 a Horizontal crestal ridge width changes (in mm) for flap and flapless sites (mean ± SD)
Baseline 4 months Change Range
n (mm) (mm) (mm) (mm)
Horizontal crestal ridge width
At crest Flap 12 8.5 ± 1.5 7.5 ± 1.5 −1.0 ± 1.1* −2.5 to -0.9
Flapless 8.3 ± 1.3 7.0 ± 1.9 −1.3 ± 1.0* −2.7 to +0.5
At 5 mm Flap 12 9.2 ± 1.6 8.6 ± 1.4 −0.6 ± 1.0 −2.5 to 1.5
Flapless 8.0 ± 1.6
*p < 0.05 between initial and 4-month values.

TA B L E 2 b Vertical ridge height change for flap and flapless sites (mean ± SD)
Location Flap Flapless Flap Flapless
Mean change (in mm) Range (in mm)
Midbuccal −0.9 ± 1.3* −0.5 ± 0.9* −2.5 to 2.5 −2.0 to 1.0
Midlingual −0.9 ± 1.3* −0.7 ± 1.1* −2.5 to 1.0 −2.5 to 1.5
Mesial −0.8 ± 0.8* −0.2 ± 0.5* −2.2 to 0.5 −1.0 to 0.7
Distal −0.9 ± 0.7* −0.3 ± 0.7* −1.8 to 0.2 −1.8 to 1.0
*p < 0.05 between initial and 4-month values.

TA B L E 2 c Soft tissue thickness changes (in mm) for flap and flapless sites (mean ± SD)
Baseline 4 months Change Range
n (mm) (mm) (mm) (mm)
Soft tissue thickness changes
Flap 12
Buccal 1.1 ± 0.5 1.3 ± 0.6 0.2 ± 0.7 −1.2 ± 1.4
Lingual 2.0 ± 1.0 2.3 ± 1.3 0.3 ± 0.7* −1.4 ± 1.6
Occlusal 1.7 ± 0.5 1.2 ± 2.9
Flapless 12
Buccal 0.9 ± 0.4 1.0 ± 0.4 0.1 ± 0.3 −0.4 ± 0.6
Lingual 2.3 ± 0.5 2.7 ± 0.5 0.4 ± 0.5* −.0.6 ± 1.3
Occlusal 2.3 ± 0.8** 0.8 ± 3.1
*p < 0.05 between initial and 4-month values; **p < 0.05 between flap and flapless groups.

3.5 Histological evaluation seven type II sites, three type III sites, and one type IV site
(Figure 3).
A high percentage of vital bone was found in both groups
(Table 3). Histological analysis revealed that flap sites
healed with 35 ± 15% vital bone, 19 ± 12% remaining graft 3.7 Soft tissue thickness
particles, 46 ± 17% trabecular space. The flapless sites
healed with 44 ± 10% vital bone, 17 ± 13% remaining graft Soft tissue thickness increased from 0.1 to 0.4 mm on the
particles, and 39 ± 9% trabecular space. There were no facial and lingual surfaces for both the flap and flapless
statistically significant differences between the flap and groups (Table 2c). This increase was statistically signifi-
flapless groups (p > 0.05) (Table 3; see also Figure S1 in the cant only on the lingual bone for both groups (p< 0.05). In
online version of the Journal of Periodontology). the flapless group, the occlusal soft tissue was significantly
thicker than in the flap group at the 4-month re-entry
(p< 0.05).
3.6 Bone quality

Bone quality was assessed subjectively as type I through 4 DISCUSSION

IV for all sites.21 The flap group comprised one type I
site, two type II sites, eight type III sites, and one type In this 4-month randomized controlled clinical study of
IV site. The flapless group consisted of one type I site, ARP, a flapless surgical technique was compared to a flap
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190 SIU et al.

TA B L E 3 Histological data at implant placement for flap and flapless sites (mean percentage ± SD)
%
Trabecular
Study group Time point n VMT (%) NVMT (%) bone
Flap 4 months 12 35 ± 15 19 ± 12 46 ± 17
Flapless 4 months 12 44 ± 10 17 ± 13 39 ± 9
Abbreviations: NVMT, non-vital mineralized tissue; VMT, vital mineralized tissue.

following tooth extraction in flap and flapless groups at 2-

and 4-month time intervals.13 Their canine study showed
increased soft and hard tissue loss in the flap group, but the
experimental model did not distinctly distinguish between
hard and soft tissue components. The human study con-
ducted by Barone et al., examining the socket healing in
flap versus flapless procedures after 3 months of healing,
showed statistically significant differences in buccolingual
width and vertical ridge height between the two groups.12
The flapless group showed more loss in the ridge height
compared to the flap group. They investigated soft and hard
tissue changes in extraction sockets grafted with cortico-
cancellous porcine bone and a collagen membrane after 3
months. The teeth included in their analysis were molars
F I G U R E 3 Bone quality as subjectively assessed as type I
and premolars. The differences in tooth type, graft materi-
through IV for both flap and flapless techniques based on the
Lekholm and Zarb classification21
als, and healing time period may have contributed to the
difference in results.
The flapless group showed a loss of 1.3 mm in cre-
reflection technique. While there are a number of pre- stal ridge width, which was slightly greater than in the
clinical and clinical studies comparing the two surgical flap group with a loss of 1.0 mm (Table 2a). Both groups
techniques for implant placement, this is one of the very lost ridge height at all locations (midbuccal, midlingual,
few human studies investigating ridge alterations as it mesial, and distal). Although these changes were not sta-
relates to ARP.22–24 For both groups, the socket was grafted tistically significant between groups, the flapless group
using a demineralized bone matrix allograft mixed with showed less loss of ridge height than the flap group. The
a mineralized particulate allograft and then capped with flap group showed a loss of ridge height of 0.8–0.9 mm at
a calcium sulfate barrier in the socket opening to contain all locations. The flapless group showed the greatest loss
the graft. There were no statistically significant differences of 0.7 mm at the midlingual site and the least loss of 0.2
in ridge dimension changes between groups in this study mm at the mesial site (Table 2b), which was comparable
(Figure 1a C and D, Figure 1b C and D). These findings to 0.9 ±0.9 mm (lingual) and 0.2 ±0.7mm (mesial) verti-
are in agreement with the results demonstrated by Araujo cal dimension loss in a flapless ridge preservation study by
and Lindhe and Filipek et al. in that there is no statisti- Barone et al.11
cally significant difference in hard tissue loss between the Whether raising a flap would negatively influence the
two surgical approaches.9,25 Araujo and Lindhe examined outcomes of ARP is controversial, but what we know is
the ridge dimension changes in an animal model following that the extent of facial bone loss after extraction depends
tooth extraction with and without flap reflection, while Fil- on several unrelated factors. The ones that seem to stand
ipek et al. did a hard and soft tissue comparative analysis out most prominently are facial bone thickness and tooth
between flap and flapless tooth extractions in humans.9,25 angulation.26 In a landmark computed tomography study,
Furthermore, the current findings also confirmed that teeth with facial bone thickness ≤1 mm had a median ver-
bone loss cannot be prevented completely irrespective of tical bone loss of 7.5 mm (62% of facial height) after just 8
the surgical approach used, which concurred with the weeks of flapless extraction.27 Interestingly, in 90% of cases
results of several other studies.9,12,19 However, our findings in the anterior maxilla, facial bone thickness is <1 mm,
differed from the conclusions of Fickl et al. and Barone and <0.5 mm in roughly 50% of cases.28–30 On the other
et al.,12,13 who evaluate healing socket sites at earlier hand, patients with a facial wall thickness of >1 mm exhib-
time intervals. Fickl et al. examined the tissue alterations ited only a median vertical bone loss of 1.1 mm27 . What
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SIU et al. 191

literature shows and this study confirms is that short-term However, the flapless technique may result in an increased
hard tissue changes following ARP with either a flapped or tissue thickness at the occlusal aspect.
flapless approach are very similar.31
Trephine cores were taken from the center of the grafted CONFLICT OF INTEREST
socket at 4 months for histological analysis (Figure S1). The authors do not have any financial interests, either
There was approximately 40% vital bone and 18% nonvital directly or indirectly, in the products or information listed
residual graft particles in each group, with no statistically in the paper.
significant differences between groups. This was consis-
tent with previous reports of the 3- to 6-month histological AU T H O R CO N T R I B U T I O N S
composition of the ridge following placement of miner- Trever L. Siu and Ziad Dib performed the surgeries. Henry
alized particulate allograft into sockets.11,19 However, the Greenwell, Trever L. Siu, and Ziad Dib contributed to the
percentage of vital bone was higher in the current study conception and design of the work. Trever L. Siu, Ziad Dib,
compared to Barone et al., who showed 22.5%.11 Perhaps and Himabindu Dukka collected and analyzed the data.
the higher percentage of vital bone at 4 months is the rea- Muhammad H. A. Saleh, Mustafa Tattan, Trever L. Siu,
son why the flapless group had relatively denser bone at and Ziad Dib contributed to the manuscript preparation.
the time of implant placement (Figure 3). Hom-Lay Wang, Mauricio G. Araujo, and Muhammad H.
This study evaluated loss of crestal ridge width in extrac- A. Saleh made critical changes and gave final approval to
tion sites with at least one adjacent tooth. Eighteen of the the manuscript. All authors gave their final approval and
24 sites had two adjacent teeth. Loss of crestal width may agreed to be accountable for all aspects of the work.
be greater when there are no adjacent teeth, when a ter-
minal tooth is extracted, and especially when all teeth in D A T A AVA I L A B I L I T Y S T A T E M E N T
an arch are being removed. This observation was in agree- The data that support the findings of this study are
ment with the findings of Chen et al., and Schropp et al.32,33 available from the corresponding author upon request.
Thus, the means and ranges reported in this study may not
be generalizable and should be limited in application to ORCID
bounded single-tooth sites. Himabindu Dukka https://orcid.org/0000-0002-6799-
Overall, changes in the crestal ridge dimensions did not 6696
show any statistically significant differences between the Muhammad H. A. Saleh https://orcid.org/0000-0001-
flap and flapless ARP techniques. The observation made 5067-7317
in our study is largely in agreement with that presented Mustafa Tattan https://orcid.org/0000-0001-7498-8064
by Araujo and Lindhe9 in that a similar amount of bone Andrea Ravidà https://orcid.org/0000-0002-3029-8130
loss was noted with both techniques, and while the latter Hom-Lay Wang https://orcid.org/0000-0003-4238-1799
was an animal study, the present study was performed in Mauricio G. Araujo https://orcid.org/0000-0003-2224-
humans. Within the limitations of this study, a flap could 982X
be used with minimal compromise to the bone when nec-
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