Mônica Misawa The alveolar process following single-

Jan Lindhe
 jo
Mauricio G. Arau
tooth extraction: a study of maxillary
incisor and premolar sites in man

Authors’ affiliations: Key words: alveolar process, bone, dimension, edentulous ridge, resorption
Mônica Misawa, Mauricio G. Ara ujo, Department
of Dentistry, State University of Maring
a, Parana,
Brazil Abstract
Jan Lindhe, Institute of Odontology, The Objective: The present investigation was performed to determine some dimensional alterations
Sahlgrenska Academy at the University of
that occur in the alveolar process of the incisor and premolar sites of the maxilla following tooth
Gothenburg, Gothenburg, Sweden
removal.
Corresponding author: Material and methods: Computer-assisted cone-beam computed tomography (CBCT) scans were
Mauricio G. Ara ujo
Department of Dentistry, State University of
obtained from the maxilla using an iCAT unit, and involved edentulous and contralateral tooth
Maring
a sites. For each site included in the study, parasagittal and axial reconstructions, 1 mm apart, were
Avenida Mandacaru, 1550 made and measurements of different variables (cross-sectional area, height, and width) performed.
87013-010
Maring
a-Paran
a-Brazil Results: The study involved 69 subjects and disclosed that the cross-sectional area and the height
Tel./Fax: +55 44 3011 9052 and width of the alveolar process of the lateral incisor site were the smallest and those of the
e-mail: odomar@hotmail.com second premolar the largest. All parameters had been significantly reduced after the completion of
the ≥1 year of healing. Thus, the overall (i) cross-sectional area was reduced from 99.1 to
65.0 mm2, (ii) the height from 11.5 to 9.5 mm, and (iii) the width from 8.5 to 3.2 mm (marginal
1/3rd), 8.9 to 4.8 mm (middle portion), and 9.0 to 5.7 mm (apical portion).
Conclusion: The removal of single tooth caused marked hard tissue diminution. The loss of hard
tissue was most pronounced in the buccal and marginal portions of the edentulous ridge that in
most sites had acquired a triangular shape.

The alveolar process is a tooth-dependent
entity (Schroeder 1986; Marks & Schroeder
1996) that undergoes marked change follow-
ing the loss/removal of single or multiple
teeth (Pietrokovski & Massler 1967; Schropp
et al. 2003; Ara
ujo et al. 2015). The healing
of the extraction socket involves modeling
and remodeling processes that result in quan-
titative as well as qualitative alterations in
the tissues of the edentulous site (Car-
daropoli et al. 2003; Ara
ujo & Lindhe 2005).
The alveolar process hereby becomes replaced
with an edentulous ridge that is both shorter
and thinner than the former alveolar process
(Pietrokovski & Massler 1967; Schropp et al.
2003). As tissue loss is more pronounced at
facial/buccal than at lingual/palatal aspects
of the ridge, its crest becomes displaced in a
lingual/palatal position (Carlsson & Ericson
1967; Carlsson et al. 1967; Pietrokovski &
Date: Massler 1967; Bergman & Carlsson 1985).
Accepted 31 August 2015
Experiments in the dog (Cardaropoli et al.
To cite this article: 2003; Ara
ujo et al. 2005, 2008; Ara
ujo &
Misawa M, Lindhe J, Ara
ujo MG. The alveolar process
following single-tooth extraction: a study of maxillary incisor Lindhe 2009) demonstrated that after single-
and premolar sites in man.
tooth extraction, the most pronounced
Clin. Oral Impl. Res. 00, 2015, 1–6
doi: 10.1111/clr.12710 hard tissue alteration occurred during the
first 2–3 months following tooth extraction.
In the initial stage, most of the bundle bone
was replaced with newly formed woven bone.
Concomitantly, resorption occurred on the
external parts of the buccal and lingual bone
plates. This loss of hard tissue was most pro-
nounced in the buccal–coronal portion.
Hence, the edentulous ridge acquired a
sloped, triangular outline (Ara
ujo & Lindhe
2005, 2009; Blanco et al. 2011).
Findings from studies in man disclosed
that, after single-tooth extraction, the major
tissue alterations occurred in early stages
(3–6 months) (Schropp et al. 2003), although
apparently various amounts of additional
diminution of the ridge could occur in a
later phase (Iasella et al. 2003; Schropp
et al. 2003; Barone et al. 2008). Furthermore,
bone loss in the single extraction site was
more prominent in the buccal than in the
lingual/palatal bone plates, and tissue loss
was more pronounced in the horizontal
direction than apico-coronal direction
(Iasella et al. 2003; Schropp et al. 2003; Bot-
ticelli et al. 2004; Sanz et al. 2010; Tomasi
et al. 2010).

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
Misawa et al
Alveolar process following single-tooth extraction
In a recent publication using cone-beam
computed tomography (CBCT) scans, dimen-
sional alterations of single-tooth extraction
sites were described (Ara
ujo et al. 2015). In
this study, 14 subjects were examined at
baseline and after 4 months of healing. It was
observed that in this interval, the height of
the buccal bone wall was more reduced than
the palatal wall (35% vs. 18%). Furthermore,
there was a substantial reduction of the
cross-sectional area of the edentulous site
(25%). As stated above, the extraction site is
not fully healed after 4 months and, hence,
additional change may occur after this time
point.
The aim of the present investigation there-
fore was to further describe dimensional
alterations that had occurred in the edentu-
lous ridge after at least 1 year of healing fol-
lowing tooth removal.
Material and methods
The Ethic Committee of State University of
Maring
a approved the study protocol.
Patients that had been referred for the
replacement of a single tooth in an edentu-
lous site of the maxillary incisor and premo-
lar regions (E site) and that in addition
presented with a periodontally healthy con-
tralateral tooth were recruited (T site). All
subjects were exposed to a radiographic
examination of the target tooth region of the
maxilla for the diagnosis of potential lesions
and the assessment of various hard tissue
dimensions at the edentulous and contralat-
eral tooth sites.
The following inclusion and exclusion cri-
teria had to be met:
Inclusion criteria
• Presence of healthy teeth lateral to the
edentulous site
• Presence of cortical bone in the crest
region of the edentulous site
• Cementoenamel junction (CEJ) of neigh-
boring teeth possible to identify in the
radiograph
Exclusion criteria
• Presence of metal artifacts in the edentu-
lous site that prevented proper radiograph
examination
• Crowding and improper tooth alignment
in the upper jaw
• Presence of granulomas, cysts, or super-
numerary teeth in the target sites
Sixty-nine subjects (40 females and 29
males) aged between 23 and 67 years (mean
40 years) met the inclusion/exclusion criteria
2 | Clin. Oral Impl. Res. 0, 2015 / 1–6
and entered the study. Twenty-four central
incisor, 21 lateral incisor, 1 canine, 14 first
premolar, and 9 s premolar sites with corre-
sponding numbers of edentulous contralateral
sites were included (Fig. 1).
Computer-assisted cone-beam computed
tomography scans were obtained using the
iCAT unit (Imaging Sciences International
Inc., Hatfield, PA, USA) and involved the
edentulous and contralateral tooth sites.
Acquisition was performed with a field of
view of 6 9 8 cm, for 20 s with the following
iCAT tomography acquisition protocol: voxel
size, 0.3 mm; gray scale, 14 bits; focal spot,
0.5 mm; image detector, amorphous silicon
flat panel; and image acquisition, single 360o
rotation. For each site included in the study,
parasagittal and axial reconstructions, 1 mm
apart, were made. A software program for
image analysis (Invivo 5.0; InVivoDental
Application 5.0, Anatomage Incâ, San Jose,
CA, USA) was used for the CBCT scan evalu-
ations that included measurements of differ-
ent variables.
Measurements
Tooth site (T site)
The following landmarks were identified on
the parasagittal reconstructions at the center
(mesiodistal) of the tooth: (i) the most coronal
portion of the alveolar process, identified as
the line that connected the buccal and palatal
crests (BC-PC; Fig. 2); and (ii) the most apical
portion of the alveolar process, identified as
an imaginary line, parallel to the axial (orbito-
meatal) plane of the skull, at the level of the
apex of the selected tooth (AB-AP; Fig. 3).
The following assessments were made:
a. The cross-sectional area (mm2) of the alve-
olar process was determined by outlining
(a)
Fig. 1. Computer-assisted cone-beam computed tomography scans representing a tooth site (a) and the correspond-
ing edentulous site (b) after ≥1 year of healing following tooth extraction.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
the surface of the hard tissue profile
between BC-PC and AB-AP (Fig. 2).
b. The cross-sectional area (mm2) of the root
invested in the alveolar bone was deter-
mined by outlining the profile of the root
extending from BC-PC to apex (Fig. 2).
c. The cross-sectional area of the bony part of
the alveolar process was calculating by
subtraction the root area from the area
occupied by the alveolar process.
d. The height of the alveolar process (mm)
was determined as the linear distance
between BC-PC and AB-AP. This distance
was measured in a direction perpendicular
to AB-AP and extended to the most coro-
nal portion of BC-PC (Fig. 2).
e. The width of the buccal as well as the
palatal bone (mm) plates was measured at
3, 5, and 7 mm apical of the CEJ of the
adjacent teeth.
Edentulous site (E site)
The most apical portion of the edentulous
ridge was identified by the imaginary AB-AP
line that was extended from the tooth to the
contralateral edentulous sites on the panora-
mic view (AB-AP; Fig. 2).
The following measurements were made at
the center (mesiodistal) of the edentulous site
between adjacent teeth (Fig. 3):
a. The cross-sectional area (mm2) was deter-
mined by outlining the profile of the sur-
face of the ridge from the level of AB-AP
to the crest (Fig. 3).
b. The height of the edentulous site (mm)
was determined as the linear distance
between AB-AP and the most coronal por-
tion of the bone crest (C; Fig. 3).
In addition, in the axial reconstructions,
the width (buccal–palatal) of the alveolar
(b)

Fig. 2. Schematic drawing describing in parasagittal
reconstruction some of the landmarks and dimensions
used to determine the cross-sectional area, the height,
and width of the alveolar process (T site). AB-AP line
identified the axial plane of the skull at the level of the
apex of the selected tooth, and BC-PC line described
the level of the buccal–palatal crest. H represents the
distance between AB-AP and BC-PC. The red line iden-
tified the outer surface of the root, while the green dot-
ted line described the outer contour (buccal–palatal) of
the alveolar process.
process and edentulous ridge were deter-
mined by measuring the distance between
the outer surface of the buccal and palatal
walls. The measurements were made at the
center of the tooth site and corresponding
location at the edentulous site (Fig. 4). The
measurements were carried out at 3, 5, and
7 mm apical to the CEJ of the adjacent teeth.
Calibration
To calibrate the examiners prior to final set
of measurements, intra-observer error was
determined by measuring the cross-sectional
area of the alveolar process on 10 randomly
selected CBCT scans. The variable was mea-
sured twice over 2 days, with an interval of
at least 24 h. The interclass correlation coef-
ficient obtained was 0.85.
Statistical analysis
Mean and standard deviation (SD) were calcu-
lated for each variable and site except for the
single canine site. Descriptive statistical
analysis of all data was performed. Kol-
mogorov–Smirnov test was performed to ver-
ify the normal distribution of the sample.
After attesting normal distribution, paired
Student’s t-test was used to evaluate the
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Misawa et al
Alveolar process following single-tooth extraction
Fig. 3. Schematic drawing describing in parasagittal
reconstruction the landmarks and dimensions used to
determine the cross-sectional area as well as height of
the edentulous ridge (E site). AB-AP line identified the
axial plane of the skull at the level of the apex of the
selected tooth. H represents the distance between AB-
AP and the crest (C).
Fig. 4. Schematic drawing describing in axial recon-
struction the width (buccal–palatal) of the T and E sites.
T represents the distance between outer surface of the
buccal and palatal bone of the alveolar process, and E
represents the distance between the buccal and palatal
bone of the edentulous ridge.
differences between edentulous and con-
tralateral tooth sites (a = 0.05).
Results
One patient only presented with an edentu-
lous canine site. This subject was excluded
from the statistical analyses.
Root dimension
The mean cross-sectional area occupied by
the roots was 49.6  15.4 mm2 (range: 40.1–
64.0 mm2); the second premolar had the lar-
gest and the lateral incisor the smallest
cross-sectional area (Table 1).
Tooth site (T site)
The overall cross-sectional area of the alveo-
lar process in the incisor and premolar region
was 99.1  30.1 mm2. The largest cross-sec-
tional area occurred in the second premolar
(119.1  27.9 mm2) and the smallest in the
lateral incisor region (82.2  23.1 mm2).
The overall area occupied by the bony part
of the alveolar process was 49.5  20.7 mm2.
In other words, the cross-sectional area of the
alveolar process was comprised of about simi-
lar amounts of root and bone tissue.
The overall height of the alveolar process
in the incisor and premolar regions examined
was 11.5  2.1 mm (Table 1). The longest
alveolar process occurred in the second pre-
molar (12.2  1.6 mm) and the shortest and
at the lateral incisor region (10.9  2.4 mm).
The mean overall of the buccal–palatal
width of the alveolar process was
8.5  1.6 mm, 8.9  1.6 mm, and
9.0  1.7 mm at 3, 5, and 7 mm levels apical
of the CEJ, respectively (Table 1). The width
of the alveolar process was greater in the pre-
molar than at the incisor regions, but was
also consistently smaller at the 3 than at the
5 and 7 mm level (Table 1).
The overall thickness of the buccal bone
wall measured of the alveolar process mea-
sured at 3, 5, and 7 mm apical of the CEJ
was 0.4  0.5, 0.8  0.4, and 0.9  0.7 mm
(Table 2). The corresponding values repre-
senting the palatal wall were 0.7  0.7,
1.5  0.9, and 2.2  1.1 mm.
The width of the buccal bone wall at the
3 mm level varied between 0.6 and 0.3 mm,
while at the 5 and 7 mm levels, the corre-
sponding range was 0.6–1.0 and 0.7–1.3 mm.
In other words, in each group of teeth, the
buccal bone wall was thinner in marginal
than in more apical levels. Furthermore, in
each category of teeth, the buccal bone wall
was consistently thinner than the corre-
sponding palatal wall.
Edentulous site (E site)
In the radiographs of all examined sites, the
marginal portion of the edentulous ridge was
lined by cortical bone that was in continuity
with the cortical bone plates of the buccal
and palatal aspects of the ridge. The trabecu-
lar bone of the ridge had a uniform structure,
and an outline representing the previous
socket walls could only occasionally be iden-
tified. In most of the sites examined, the
edentulous ridge was triangular in shape with
its base in direct continuity with the basal
bone of the maxilla.
The mean overall cross-sectional area of
the edentulous ridge was 65.0  29.8 mm2
(Table 1). In comparison with the alveolar
process, the edentulous sites were on the
average between 34.1  20.5 mm2 (34%)
3 | Clin. Oral Impl. Res. 0, 2015 / 1–6
Misawa et al
Alveolar process following single-tooth extraction

Table 1. Mean values (SD) describing various parameters characterizing the dimensions of the root, the alveolar process, and the corresponding
edentulous ridge. Cross-sectional area (mm2), height, and width (mm). Note that the width was measured at three different levels (3, 5, and 7 mm)
apical of the CEJ of neighboring teeth. It should be observed that the results from the measurements of the single canines sites were neither
included in the mean values calculations nor in the statistical analyses
Central incisor Lateral incisor Canine First premolar Second premolar Overall
n = 24 n = 21 n=1 n = 14 n=9 n = 68
Cross-sectional area
Alveolar process 103.3  32.4* 82.2  23.1* 127.8 107.0  21.5* 119.1  27.9* 99.1  30.1*
Root portion 46.5  11.7 40.1  10.2 72.5 61.2  13.0 64.0  16.3 49.6  15.4
Bone portion 56.8  24.2 42.5  18.4 55.27 45.8  14.7 55.1  17.6 49.5  20.7
Edentulous ridge 72.7  34.4 51.9  28.8 80.3 66.3  18.6 74.7  25.8 65.0  29.8
Reduction† 30.6  32.3 (30%) 30.4  17.5 (37%) 40.7  20.3 (38%) 44.3  29.0 (37%) 34.1  20.5 (34%)
Height
Alveolar process 11.9  2.2* 10.9  2.4* 11.7 11.4  1.2* 12.2  1.6* 11.5  2.1*
Edentulous ridge 10.2  2.8 8.4  2.5 9.4 9.8  1.8 9.9  3.2 9.5  2.6
Reduction 1.6  1.7 (14%) 2.5  1.7 (23%) 1.7  1.4 (15%) 2.5  2.0 (21%) 2.0  1.7 (17%)
Width
3 mm
Alveolar process 8.8  1.8* 7.6  1.2* 10.1 8.7  0.9* 9.8  1.1* 8.5  1.6
Edentulous ridge 3.5  2.6 2.9  2.7 3.1 3.0  1.7 3.2  3.7 3.2  2.7
Reduction 5.3  2.2 (61%) 4.7  2.4 (65%) 5.7  2.8 (65%) 6.6  3.8 (67%) 5.3  2.7 (62%)
5 mm
Alveolar process 9.0  1.9* 8.2  1.4* 12.0 9.2  1.0* 10.1  1.2* 8.9  1.6*
Edentulous ridge 4.8  2.7 4.2  2.7 7.3 4.7  2.8 5.9  3.2 4.8  2.8
Reduction 4.2  2.8 (47%) 3.9  2.2 (49%) 4.6  3.0 (50%) 4.2  3.0 (42%) 4.1  2.7 (46%)
7 mm
Alveolar process 9.1  1.6* 8.2  1.7* 11.8 9.6  1.0* 9.9  1.2* 9.0  1.7*
Edentulous ridge 5.2  2.7 5.1  2.5 10.3 6.1  2.0 7.5  1.8 5.7  2.5
Reduction 3.3  3.3 (43%) 3.1  2.1 (38%) 3.4  2.1 (35%) 2.4  2.0 (24%) 3.1  2.6 (34%)
*
denotes a significant difference between the alveolar process and the edentulous site (P < 0.05).
†denotes the difference between the alveolar process and edentulous ridge cross-sectional area.

Table 2. Mean values (SD) describing the width (mm) of the buccal and palatal walls at 3, 5, and
7 mm below the cementoenamel junction of the neighboring teeth. It should be observed that number of sites presented with a ridge that
the results from the measurements of the single canines sites were neither included in the mean was <4 mm at the 3 mm level. Indeed, the
values calculations nor in the statistical analyses
number of relatively wide E sites (≥6 mm) at
Central incisor Lateral incisor Canine First premolar Second premolar Overall this level was conspicuous small.
Buccal wall Table 4 presents the number of edentulous
3 mm 0.4  0.5 0.4  0.4 0.5 0.3  0.5 0.6  0.5 0.4  0.5
sites with different amount of remaining
5 mm 0.8  0.3 0.6  0.4 0.6 0.8  0.6 1.0  0.5 0.8  0.4
7 mm 1.0  0.7 0.7  0.5 0.5 1.0  1.0 1.3  0.5 0.9  0.7 cross-sectional area. It was observed that 12
Palatal wall sites (of which 8 were lateral incisors) had a
3 mm 0.7  0.9 0.7  0.6 0.5 0.5  0.6 0.9  0.7 0.7  0.7 cross-sectional area of <40 mm2, while 37 of
5 mm 1.8  1.0 1.3  0.9 1.5 1.3  0.7 1.9  0.6 1.5  0.9
7 mm 2.5  1.3 2.0  1.1 2.1 1.9  0.7 2.3  0.8 2.2  1.1
68 sites (54%) had a cross-sectional area of
≥60 mm2.

smaller. The amount of diminution expressed
in mm2 was largest in the second premolar
(44.3 mm2) and smallest in the lateral incisor
region (30.4 mm2). In all sites examined, the
cross-sectional area of the E sites was signifi-
cantly smaller than the corresponding dimen-
sion of the T sites.
The mean overall height of the edentulous
ridge was 9.5  2.6 mm (range: 8.4–10.2 mm;
Table 1). This dimension was found to be
between 1.6 and 2.5 mm shorter than the
corresponding value of the alveolar process.
The reduction of the height was greater at
the lateral incisor and second premolar sites
than at central incisor and first premolar
sites. In all sites examined, the height of the
E sites was significantly smaller than the cor-
responding parameter of the T sites.
The mean overall width of the edentulous
ridge at 3, 5, and 7 mm levels apical of the
CEJ were, respectively, 3.2  2.7, 4.8  2.8,
and 5.7  2.5 mm. The amount of width
diminution was consistently greater at the
3 mm level than at the 5 and 7 mm levels
(Table 1). Thus, the diminution at the 3 mm
level amounted to 62%, while at the 5 mm
and 7 mm level, the corresponding diminu-
tion was smaller (46% and 34%). At all levels
of examination, the width of the E sites was
significantly smaller than that of the T sites.
In Table 3, the width of the alveolar pro-
cess (T Sites) and the corresponding edentu-
lous sites (E Sites) was compared at different
levels apical of the CEJ of the adjacent teeth.
In the T Sites, at all 3 levels of examination
(3, 5, and 7 mm), 43 of 45 sites in the central
incisor and premolar regions were ≥7 mm
wide. In the lateral incisor sites, however, 8
of 21 sites were <7 mm wide. In contrast, in
the edentulous group, a comparative large
Discussion
In the present study, CBCT reconstructions
were used to determine dimensional alter-
ations that had occurred in single extraction
sites that had been edentulous for ≥1 year.
The study disclosed that the (i) cross-sec-
tional area, as well as the (ii) height, and (iii)
width of the alveolar process had become sig-
nificantly reduced after the completion of the
healing process. It was also demonstrated
that the alterations were more conspicuous
in the coronal third than in more apical
regions of the alveolar ridge.
In the current set of measurements, it was
assumed that the dimensions of the teeth
and alveolar process at the right and left sides
of maxilla were similar. The basis for this
hypothesis was findings presented by Pietro-
kovski & Massler (1967). They concluded

4 | Clin. Oral Impl. Res. 0, 2015 / 1–6 © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Misawa et al
Alveolar process following single-tooth extraction

Table 3. Number of sites with varying amounts of buccal–palatal width at 3, 5, and 7 mm below the cementoenamel junction of the neighboring
teeth at tooth site (T Site) and Edentulous site (E Site)
Central Incisor Lateral Incisor Canine First Premolar Second Premolar

T Sites E Sites T Sites E Sites T Sites E Sites T Sites E Sites T Sites E Sites
3 mm below CEJ
<2 mm 0 8 0 9 0 0 0 6 0 4
≥2 <3 mm 0 2 0 1 0 0 0 0 0 2
≥3 <4 mm 0 3 0 4 0 1 0 3 0 0
≥4 <5 mm 0 4 0 0 0 0 0 1 0 0
≥5 <6 mm 0 4 2 4 0 0 0 2 0 1
≥6 <7 mm 1 2 6 1 0 0 1 1 0 0
≥7 mm 23 1 13 2 1 0 13 1 9 2
5 mm below CEJ
<2 mm 0 3 0 4 0 0 0 3 0 1
≥2 <3 mm 0 2 0 4 0 0 0 1 0 0
≥3 <4 mm 0 4 0 2 0 0 0 0 0 1
≥4 <5 mm 0 3 0 1 0 0 0 0 0 1
≥5 <6 mm 0 6 0 4 0 0 0 3 0 1
≥6 <7 mm 1 3 7 1 0 0 0 4 0 2
≥7 mm 23 3 14 5 1 1 14 3 9 3
7 mm below CEJ
<2 mm 0 2 0 2 0 0 0 1 0 0
≥2 <3 mm 0 3 0 4 0 0 0 0 0 0
≥3 <4 mm 0 1 0 0 0 0 0 1 0 0
≥4 <5 mm 0 3 0 2 0 0 0 1 0 1
≥5 <6 mm 0 4 1 3 0 0 0 1 0 2
≥6 <7 mm 1 2 5 6 0 0 0 4 0 0
≥7 mm 19 5 14 3 1 1 14 6 9 6

Table 4. Number of edentulous sites with different amounts of cross-sectional area (mm2)
Central incisor Lateral incisor
n = 24 n = 21
<40 2 8
≥40 <60 8 6
≥60 <80 7 4
≥80 <100 2 2
≥100 5 1
that (i) “the human dental arch (teeth and
adjacent tissues) is symmetrical but not an
identical complex in most patients” and (ii)
“it is possible to superimpose the right and
left side of an individual’s dental arches with
an acceptable margin of accuracy.” Further-
more, Pietrokovski & Massler (1967) reported
that the dimensional change that occurred
following tooth extraction was similar in the
left and right sides of the jaws.
In the present study, the selected extrac-
tion sites had been edentulous for at least
1 year following tooth removal. This healing
interval was chosen for different reasons.
First of all, Schropp et al. (2003) reported on
“bone healing and soft tissue contour
changes following single-tooth extraction” in
man and demonstrated that, although most
dimensional ridge alteration occurred during
the first 3–6 months following tooth extrac-
tion, additional resorption occurred in the
6- to 12-month interval. This finding was
supported by the outcome of a systematic
review (Tan et al. 2012). The authors
included human and animal studies that
Canine First premolar Second premolar Overall
n=1 n = 14 n=9 n = 68
0 1 1 12
0 4 1 19
0 5 3 19
1 4 3 12
0 0 1 7
evaluated single extraction sites and reported
that most of the dimensional alterations
occurred during the first 6 months following
tooth extractions. Following this interval,
only minor change took place in the edentu-
lous site. Secondly, experiments in the dog
revealed that the corticalization of the
entrance of the socket site represented a final
event of bone modeling, after which only
limited change occurred in the edentulous
ridge (Cardaropoli et al. 2003; Ara
ujo &
Lindhe 2005). In the present study, all extrac-
tion sites selected for analysis showed the
presence a well-defined layer of cortical bone
covering the crest and, thus, identified as
“fully healed sites.”
The measurements made in the CBCT
scan of the current sample showed that the
cross-sectional area of the tooth site was
comprised of similar proportions of bone and
root structure (Table 1). Subsequent to the
completion of socket healing, the overall
cross-sectional area of the edentulous site
had become markedly reduced ( 34.1 mm2;
34%). In addition, the data describing the
width of the ridge at tooth and edentulous
sites at all 3 levels (3, 5, 7 mm; Table 1)
showed that in the edentulous sites, the
width was significantly narrower than in the
tooth sites. However, the area occupied by
bone tissue had indeed increased from about
50 to 65 mm2 (Table 1). Obviously, this addi-
tional new bone was not formed on the outer
sides of the buccal and palatal bone walls but
inside the previous socket. On the other
hand, it should be noted that the tooth sites
were not equally distributed (there were more
incisors that canine and premolars sites) and
this may have affected the overall amount of
ridge reduction.
The measurements made in the scans
demonstrated that although most diminution
had occurred in the marginal portion of the
edentulous site (>60%), significant reduction
of the cross-sectional area also occurred in
more apical portions of the ridge (5 mm level
≥40%, 7 mm level ≥30%). This indicates that
the edentulous site, in comparison with the
corresponding tooth site, was not only mark-
edly smaller but had also assumed a triangu-
lar shape. This conclusion is further
confirmed when the number of sites (Table 3)
with varying amount of remaining horizontal
ridge dimension (width) was evaluated. Thus,
at the 3 mm level, most sites were ≤4 mm
wide, while at the 7 mm level, most sites
were ≥5 mm. This observation is only partly
in agreement with findings from experiments
in the dog (Ara
ujo et al. 2008; Ara
ujo &

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 5 | Clin. Oral Impl. Res. 0, 2015 / 1–6
Misawa et al
Alveolar process following single-tooth extraction
Lindhe 2009) that indicated that during
socket healing, the diminution was confined
to the marginal 1/3rd, while more central and
apical portions of the edentulous ridge
remained unchanged. In other words, even if
the marginal portion in the current study
was most exposed to resorption, the entire
ridge apparently underwent diminution.
In a study by Pietrokovski & Massler
(1967), it was reported that following tooth
extraction, the resorption of the buccal por-
tion of the edentulous site was much more
pronounced than the reduction of the
palatal–lingual portion. Similar findings were
presented by Botticelli et al. (2004), Sanz
et al. (2010), and Tomasi et al. (2010) who
studied bone wall changes following implant
placement in fresh extraction socket and
reported that more bone loss occurred at buc-
cal than on the palatal/lingual walls. Based
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