Quality Resource Guide l Alveolar Ridge Preservation Following Tooth Extraction 4th Edition 5 www.metdental.com 4mm apical to the cemento-enamel junction tooth was 0.13mm, 0.23mm, 0.60mm, 0.99mm for mandibular first premolar, second premolar, first molar and second molar, respectively. Cardaropoli et al. (2014) showed that in non-grafted premolar and molar sites there was an inverse relationship between buccal plate thickness and ridge width changes. The greater the thickness, the less ridge resorption was observed. Collectively, these studies suggests that ridge preservation is probably warranted in anterior maxillary sites while sites with thicker bone wall plate, especially molar sites may not be as susceptible to alveolar ridge dimension alterations following extraction. To illustrate the latter point, Walker et al. (2017) compared the healing following single molar extraction with and without ridge preservation. When ridge preservation was performed a combination of FDBA and a non-resorbable dPTFE membrane was used. Three months after extraction, radiographic ridge dimensions were assessed prior to single implant placement. The authors reported that no significant ridge width reduction difference was seen. However, the sites which did not received ridge preservation required more frequently bone grafting at the time of implant placement (25% of the time in extraction alone sites vs. 10% in ridge preserved sites). Technique After local anesthesia has been delivered, the least traumatic possible extraction is performed with care to maintain all the bony walls of the extraction socket intact. For this purpose, periotomes may be preferred over larger, bulkier traditional elevators. Once the tooth has been extracted, the integrity of the buccal bone wall plate should be checked and if all the walls are intact, the grafting procedure can be performed. Small quantities of graft should be applied successively and condensed in the extraction socket. This allow for an optimal filling of the socket. The most coronal part of the socket can be covered with a collagen wound dressing before a figure eight suture is placed over the extraction site to maintain the stability of the graft. In instances where, despite careful extraction, the buccal plate has fractured, digital pressure applied on the buccal surface of the extraction site will lead to soft tissue depression into the extraction site confirming the loss of integrity of the buccal wall plate. A full-thickness mucoperiosteal flap should be elevated to expose the full extent of the extracted site including the buccal dehiscence. A releasing incision, at least a tooth away from the extraction site, may be necessary to allow flap elevation and access for visualization of the defect. Grafting and contouring of the site should be performed and a membrane placed over the grafted site. A periosteal incision may help in advancing the flap Figures 2 and 3 Tooth #10 is scheduled for extraction and replacement with an implant is planned Figure 4 Tooth #10 has been extracted with a least traumatic technique coronally before it is sutured back. The healing time should be extended considering the absence of buccal bone plate. Post-operative care usually includes the prescription of systemic antibiotics for 7 to 10 days, analgesics and rinsing with a 0.12% chlorhexidine solution twice a day for 7 to 14 days. Conclusion Ridge preservation is a straightforward procedure and, if performed at the time of extraction, may prevent drastic ridge dimensions alterations. This, in turn, maximizes the chances to proceed with dental implant placement, once healing has occurred, with little or no need for technique-sensitive guide bone regeneration (GBR) procedures. Acknowledgements All the clinical illustrations in the present manuscript are the courtesy of the Graduate Periodontics Program at the University of Texas Health Science Center at San Antonio (UTHSCSA) and the United States Air Force Periodontics Residency Program at Lackland Air Force Base, TX. Figures 5 and 6 All the walls were intact and the site was grafted with FDBA and a resorbable collagen wound dressing (CollaTape®) was placed over the graft and the site was sutured.