Evaluation of hard tissue replacement composite graft material as a ridge preservation/augmentation material in conjunction with immediate hydroxyapatite-coated dental implants

BACKGROUND: Immediate placement of dental implants (DI) in fresh extraction sockets is associated with remaining voids around the DI and often a partial dehiscence or thin facial alveolar plate. Bone replacement grafts are often used to correct these problems. This study evaluated the use of a layered composite of PMMA (poly-methyl-methacrylate), PHEMA (poly-hydroxyl-ethyl-methacrylate), and calcium hydroxide grafts (HTR) as a ridge preservation/ augmentation material used in conjunction with an immediate DI placement technique. METHODS: Twenty-three patients requiring 1 or 2 extractions that were treatment planned for immediate DI placement received 4.0 or 3.25 mm diameter hydroxyapatite-coated cylindrical implants in the extraction sockets. HTR was used to fill the remaining socket void and enhance the facial ridge width. A collagen hemostatic was placed to cover the DI sites, flaps released, and primary closure attempted with sutures. DI uncovering was performed at about 6 months. Measurements were taken to the nearest 0.5 mm of the internal socket width and total ridge width at DI placement and uncovering. RESULTS: Thirty DIs were placed in the 23 patients. Mean initial internal socket width was 6.9 mm. The total ridge width showed a mean change from 9.1 mm to 8.4 mm; 60% of the areas showed a net increase or no change, while 40% showed a decrease in overall ridge width. DI success rate was 97% out to 6 months of loading. CONCLUSION: The results of this study suggest that HTR is a useful adjunct in the placement of immediate DIs for filling of socket voids and preservation of ridge width.     

Use of HTR synthetic bone grafts in conjunction with immediate dental implants

Immediate placement of dental implants in fresh extraction sockets is associated with remaining voids around the implants and often a partial dehiscence or thinning of the facial alveolar plate. Nine patients had Bioplant HTR synthetic bone used as a ridge preservation/augmentation material in conjunction with immediate placement of 10 implants. Hard tissue replacement (HTR) was used to fill the remaining socket void and enhance the facial ridge width, and the wound closed as completely as possible. Dental implants were uncovered at approximately 6 months. Measurements taken of the internal socket width and total ridge width at the implant placement and uncovering showed the mean internal socket width was maintained (7.2 mm vs 6.9 mm), and the total ridge width exhibited a mean change from 9.6 mm to 8.8 mm. Of the 10 implant sites, 7 showed a net increase, 2 no change, and 1 a decrease in overall ridge width. All 10 implants were restored for at least 6 months. These clinical results suggest that HTR is a useful adjunct in the placement of immediate dental implants for the preservation of ridge width and provides a good base for functional and esthetic prosthetic reconstruction.     

Microcomputed Tomographic Analysis of the Alveolar Ridge Alteration around Extraction Sites with and without Immediate Implants Placement: In Vivo Study

Background: The aim was to assess the alveolar ridge alteration around extraction sites with and without immediate implants according to extraction socket classification (ESC) using microcomputed tomography (micro‐CT). Material and Methods: Ten beagle dogs (mean age and weight: 24 ± 0.83 months and 13.8 ± 0.49 kg, respectively) were randomly divided into three groups according to the ESC. In Group 1 (ESC‐I), bilateral first and third premolars were extracted and replaced with immediate implants. In Group 2 (ESC‐II), two adjacent premolars were extracted with one immediate implant placement in the mesial socket in the maxilla and in the distal socket in the mandible. In Group 3 (ESC‐III), three adjacent teeth were extracted and an immediate implant was placed in the central socket. Primary closure was achieved using resorbable sutures. Buccal sites with dehiscence defects were excluded. After 4 months, subjects were sacrificed and alveolar ridge widths were measured at 1 mm interval in axial and sagittal views, using micro‐CT in sites with and without immediate implants. Results: In sites without immediate implant placement, alveolar ridge width was significantly higher in Group 1(6.1 ± 1.35 mm) than Group 3 (4.14 ± 1.53 mm) (p < .05). In sites with immediate implant placement, the alveolar ridge width was higher among sites in Group 1 (6.4 ± 3.8 mm) than Group 2 (4.8 ± 0.46 mm) (p < .05) and Group 3 (5.02 ± 0.84 mm) (p < .05). Overall, between each corresponding group in both sites with and without immediate implant placement at 1 mm thickness, there was no significant difference in the alveolar ridge widths. Conclusion: With the exception of Group 1 (ESC‐I), immediate implant placement did not prevent or minimize bone remodeling in extraction sites according to ESC.     

Evaluation of Healing at Molar Extraction Sites With and Without Ridge Preservation: A Randomized Controlled Clinical Trial

Background: To date, limited evidence is available specifically evaluating ridge preservation (RP) and implant placement in molar sites. The primary aim of this study is to radiographically compare alveolar ridge changes with and without RP with cone‐beam computed tomography (CBCT). Methods: This parallel, two‐arm randomized clinical trial included 40 patients evenly distributed between two treatment groups. After molar extraction, sites were allowed to heal naturally or received RP with freeze‐dried bone allograft covered by a non‐resorbable dense polytetrafluoroethylene membrane. CBCT scans were taken immediately and 3 months postextraction, and then a dental implant was placed. Width and height measurements were made radiographically. Results: Significantly greater loss in alveolar ridge height was found in molar sites allowed to heal without RP on the buccal aspect of the socket (RP: ?1.12 ± 1.60 mm versus no RP: ?2.60 ± 2.06 mm, P = 0.01). No significant difference in ridge width loss was found between groups. Two‐thirds ridge width reduction was experienced on the buccal aspect in sites without RP, but width loss was evenly distributed between buccal and lingual aspects when RP was performed. Bone grafting at time of placement was required in 25% of implants in the group without RP versus 10% of implants in the RP group. Conclusions: In molar extraction sites without RP, significantly more reduction in ridge height occurred, and the majority of ridge width loss was localized to the buccal aspect. When RP was performed, ridge width loss was not significantly decreased, but the loss was evenly distributed between facial and lingual aspects of the extraction site.     

前牙美学区牙槽嵴保存延期种植的临床研究

目的 探讨前牙美学区即刻拔牙后采用牙槽嵴保存技术对延期种植的美学修复影响.方法 收集选取2016—2018年于南京医科大学附属口腔医院就诊的患者20例,其中男8例、女12例,所有患者美学区无法保留患牙且骨质缺损较严重,需行前牙美学修复,行前牙微创拔牙,拔牙后即刻行植骨术和胶原膜隔离,引导拔牙窝骨再生,实现位点保存.6个...     

Alveolar ridge preservation in the esthetic zone

In the esthetic zone, in the case of tooth extraction, the clinician is often confronted with a challenge regarding the optimal decision‐making process for providing a solution using dental implants. This is because, after tooth extraction, alveolar bone loss and structural and compositional changes of the covering soft tissues, as well as morphological alterations, can be expected. Ideally, the therapeutic plan starts before tooth extraction and it offers three options: spontaneous healing of the extraction socket; immediate implant placement; and techniques for preserving the alveolar ridge at the site of tooth removal. The decision‐making process mainly depends on: (i) the chosen time‐point for implant placement and the ability to place a dental implant; (ii) the quality and quantity of soft tissue in the region of the extraction socket; (iii) the remaining height of the buccal bone plate; and (iv) the expected rates of implant survival and success. Based on scientific evidence, three time‐periods for alveolar ridge preservation are described in the literature: (i) soft‐tissue preservation with 6–8 weeks of healing after tooth extraction (for optimization of the soft tissues); (ii) hard‐ and soft‐tissue preservation with 4–6 months of healing after tooth extraction (for optimization of the hard and soft tissues); and (iii) hard‐tissue preservation with > 6 months of healing after tooth extraction (for optimization of the hard tissues).     

Preserving the socket dimensions with bone grafting in single sites: an esthetic surgical approach when planning delayed implant placement

Recent advancements in barrier membranes, bone grafting substitutes, and surgical techniques have led to a predictable arsenal of treatment methods for clinicians who practice implant dentistry. The contemporary clinician is supplied with proven knowledge, substantiated materials, and instrument inventory that allows implant placement in cases that used to be reserved for the specialist in the past because of their complexity. Nowadays, postextraction alveolar ridge maintenance can be a predictable procedure and can certainly aid the clinician in preventing ridge collapse, thereby allowing for implant placement in a position that satisfies esthetics and function. Extraction socket maintenance for future implant therapy does not rule out immediate implant placement but rather provides an additional option when treatment planning implant patients. This article will focus on the concept of extraction socket preservation using regenerative materials. It will describe a technique suggested by the authors to resist bone resorption and soft tissue shrinkage following tooth extraction.     

Ridge preservation with freeze-dried bone allograft and a collagen membrane compared to extraction alone for implant site development: a clinical and histologic study in humans

BACKGROUND: Tooth extraction typically leads to loss of ridge width and height. The primary aim of this 6-month randomized, controlled, blinded, clinical study was to determine whether ridge preservation would prevent post-extraction resorptive changes as assessed by clinical and histologic parameters. METHODS: Twenty-four patients, 10 males and 14 females, aged 28 to 76 (mean 51.5 +/- 13.6), requiring a non-molar extraction and delayed implant placement were randomly selected to receive either extraction alone (EXT) or ridge preservation (RP) using tetracycline hydrated freeze-dried bone allograft (FDBA) and a collagen membrane. A replaced flap, which did not completely cover the sockets, was used. Following extraction, horizontal and vertical ridge dimensions were determined using a modified digital caliper and an acrylic stent, respectively. Prior to implant placement, a 2.7 x 6.0 mm trephine core was obtained and preserved in formalin for histologic analysis. RESULTS: The width of the RP group decreased from 9.2 +/- 1.2 mm to 8.0 +/- 1.4 mm (P<0.05), while the width of the EXT group decreased from 9.1 +/- 1.0 mm to 6.4 +/- 2.2 mm (P<0.05), a difference of 1.6 mm. Both the EXT and RP groups lost ridge width, although an improved result was obtained in the RP group. Most of the resorption occurred from the buccal; maxillary sites lost more width than mandibular sites. The vertical change for the RP group was a gain of 1.3 +/- 2.0 mm versus a loss of 0.9 +/- 1.6 mm for the EXT group (P<0.05), a height difference of 2.2 mm. Histologic analysis revealed more bone in the RP group: about 65 +/- 10% versus 54 +/- 12% in the EXT group. The RP group included both vital bone (28%) and non-vital (37%) FDBA fragments. CONCLUSIONS: Ridge preservation using FDBA and a collagen membrane improved ridge height and width dimensions when compared to extraction alone. These dimensions may be more suitable for implant placement, especially in areas where loss of ridge height would compromise the esthetic result. The quantity of bone observed on histologic analysis was slightly greater in preservation sites, although these sites included both vital and non-vital bone. The most predictable maintenance of ridge width, height, and position was achieved when a ridge preservation procedure was employed.     

上前牙位点保存的临床研究

目的:探讨使用羟基磷灰石骨粉复合生物胶原材料进行拔牙位点保存的临床效果。方法:对30例拔除前牙的患者随机分组,试验组15例,拔牙同期在拔牙窝内植入羟基磷灰石骨粉,生物胶原材料覆盖表面关闭拔牙窝,临时义齿修复缺失牙并在位点处维持软组织形态;对照组15例,拔牙后常规处理,让拔牙窝内充满自然形成的血凝块。6个月后复诊,观察拔牙窝愈合情况,测量牙槽嵴的高度、宽度和牙间乳头的位置,采用两独立样本t检验进行统计学分析,使用SPSS17.0统计学软件分析处理数据。结果:试验组拔牙窝愈合良好,牙槽骨丰满,牙龈乳头形态得以保留,牙龈边缘连续一致;而对照组牙槽嵴吸收、萎缩,高度降低、宽度缩小明显,牙龈乳头萎缩甚至消失。实验组和对照组间牙槽嵴高度、宽度和牙间乳头的变化差异均具有统计学意义(P＜0.05)。结论:羟基磷灰石骨粉复合生物胶原材料起到了保存拔牙后牙槽骨骨量的作用,及时的临时义齿修复很好的维持了软组织形态。     

Dimensional ridge alterations following socket preservation using a nanocrystalline hydroxyapatite paste: a histomorphometrical study in dogs

The aim of the study was to evaluate the histological response and dimensional ridge alterations following application of a nanocrystalline hydroxyapatite paste (NHA) into fresh extraction sockets in dogs. Immediately following vertical tooth separation and extraction, NHA was inserted in the extraction socket of the second molar in the lower jaws of 10 dogs. Untreated extraction sites on the opposite side served as controls. Wounds were closed using resorbable sutures after vertical flap elevation. After three and six months, 5 animals were killed. Lingual and buccal bone height, alveolar wall and total bone width 1, 3 and 5mm underneath the top of the crest were evaluated. Histological analysis revealed a high variability of NHA resorption and osteoconductive properties with different rates of material resorption. No statistically significant differences could be observed between the corresponding aspects of test and control sites. Both groups revealed higher alveolar wall resorption on the buccal than on the lingual side at both time periods. NHA does not seem to be useful for socket preservation procedures since it failed to prevent dimensional ridge alterations while revealing osseous integration but unpredictable material resorption. The role of non-resorbed hydroxyapatite remnants for implant placement is unclear and requires further investigation.     

Current perspectives on the role of ridge (socket) preservation procedures in dental implant treatment in the aesthetic zone

Augmentation of the extraction socket (ridge preservation) is increasingly being advocated in anticipation of implant placement. The aim of this article is to review the available evidence with regards to ridge preservation procedures, investigating whether these techniques improve dental implant treatment outcomes. Evidence is examined to compare these techniques to other treatment alternatives such as implant placement with simultaneous lateral augmentation. An electronic PubMed search was conducted using search terms relevant to assessing treatment outcomes in association with ridge preservation. Titles were screened and full text obtained where relevant. Further full text articles were obtained from analysis of those papers yielded from the original search. Twenty‐two papers were finally selected for analysis. Ridge preservation techniques are effective in minimizing post‐extraction alveolar ridge contraction. However, there is insufficient evidence to suggest that the use of these techniques in conjunction with dental implant treatment improves implant treatment outcomes. Furthermore, ridge preservation does not necessarily eliminate the need for further simultaneous augmentation at the time of implant placement. The delayed healing associated with ridge preservation using socket grafting necessitates a commitment to a delayed placement protocol. The extended treatment time, compromised healing and expense related to ridge preservation suggests a more cautious approach with regards to the indication of such techniques.     

Dimensional ridge alterations following immediate implant placement in molar extraction sites: a six-month prospective cohort study with surgical re-entry

Aim: To assess dimensional ridge alterations following immediate implant placement in molar extraction sites.
Material and methods: Twelve subjects received 12 immediate transmucosal implants in molar extraction sites. Peri-implant defects were treated according to the principles of Guided Bone Regeneration by means of a deproteinized bone substitute and a bioresorbable collagen membrane. Changes in vertical (IS-BD, CREST-BD) and horizontal distances (EC-I, IC-I) of alveolar bony walls to the bottom of the defects (BD) and to the implant surfaces (I) were compared between implant placement and surgical re-entry at 6 months.
Results: The implant survival rate at 6 months was 100%. Statistically significant differences ( P <0.01) were observed in the mean changes in vertical distances IS-BD and CREST-BD between baseline and re-entry. At re-entry, all peri-implant marginal defects assessed from the internal socket wall to the implant surface (IC-I) were healed. The residual combined thickness of the buccal wall with the newly formed peri-implant bone at sites with an initial thickness of 1 mm was statistically significantly smaller ( P <0.05) compared with that of sites with an initial buccal thickness of 2 mm (2.50 ± 0.76 vs. 4±0 mm).
Conclusions: The marginal defects around immediate implants placed in molar extraction sites were completely filled after 6 months of healing through de novo bone formation. Bone resorption was observed from the external aspects of the buccal and oral socket walls. Dimensional changes of the external socket walls were mostly pronounced at the buccal aspects.     

Porcine‐Derived Xenograft Combined with a Soft Cortical Membrane versus Extraction Alone for Implant Site Development: A Clinical Study in Humans

Background: An adequate alveolar crest is essential for implant placement in terms of esthetics and function. The objective of this randomized clinical trial was to compare the preservation of the alveolar ridge dimensions following tooth extraction using porcine‐derived xenograft combined with a membrane versus extraction‐alone (EXT) sites. Methods: Fifteen patients who required double extraction of contralateral premolars and delayed implant placement were randomly selected to receive both ridge‐preservation procedure and EXT. The test sites (alveolar ridge preservation [ARP]) included 15 sockets treated using a corticocancellous porcine bone xenograft (OsteoBiol® Gen‐Os; Tecnoss srl, Giaveno, Italy) associated with a soft cortical membrane (OsteoBiol® Lamina; Tecnoss srl), while the corresponding control sites (EXT) were left without grafting for EXT. Horizontal and vertical ridge dimensions were recorded at baseline and 6 months after extractions. Results: After 6 months, the EXT sites showed a significantly greater reabsorption of the buccolingual/palatal dimension of the alveolar ridge (3.7 ± 1.2 mm) compared with the ARP sites (1.8 ± 1.3 mm). The mean vertical ridge height reduction in the control sockets was 3.1 ± 1.3 mm at the buccal sites and 2.4 ± 1.6 mm at the lingual sites compared with 0.6 ± 1.4 and 0.5 ± 1.3 mm, respectively, in the test sockets. The differences between test and control sockets were not significant for the mesial and distal measurements. Conclusions: The placement of a porcine xenograft with a membrane in an extraction socket can be used to reduce the hard tissue reabsorption after tooth extraction compared with EXT.     

Postextraction maintenance of the alveolar ridge: rationale and review

Alveolar ridge resorption has long been considered an unavoidable consequence of tooth extraction and can be a significant problem in implant and restorative dentistry. Postextraction maintenance of the alveolar ridge minimizes residual ridge resorption and allows placement of an implant that satisfies both esthetic and functional criteria. Guided bone-regeneration techniques and the use of bone-replacement materials have been shown to enhance socket healing and potentially modify the resorption process. The prime indication for socket preservation is the prevention of alveolar-bone and soft-tissue collapse, which would cause unacceptable prosthesis esthetics. This review describes the rationale behind socket preservation, and the various techniques and materials used for extraction site grafting.     

Ridge Preservation Comparing Socket Allograft Alone to Socket Allograft Plus Facial Overlay Xenograft: A Clinical and Histologic Study in Humans

Background: Previous studies of ridge preservation showed a loss of ≈18% or 1.5 mm of crestal ridge width in spite of treatment. The primary aim of this randomized, controlled, masked clinical trial is to compare a socket graft to the same treatment plus a buccal overlay graft, both with a polylactide membrane, to determine if loss of ridge width can be prevented by use of an overlay graft. Methods: Twelve patients who served as positive controls received an intrasocket mineralized cancellous allograft (socket group), and 12 patients received the same socket graft procedure plus buccal overlay cancellous xenograft (overlay group). Horizontal ridge dimensions were measured with a digital caliper, and vertical ridge changes were measured from a stent. Before implant placement, at 4 months, a trephine core was obtained for histologic analysis. Results: The mean horizontal ridge width at the crest for the socket group decreased from 8.7 ± 1.0 to 7.1 ± 1.5 mm for a mean loss of 1.6 ± 0.8 mm (P <0.05), whereas the same measurement for the overlay group decreased from 8.4 ± 1.4 to 8.1 ± 1.4 mm for a mean loss of 0.3 ± 0.9 mm (P >0.05). The overlay group was significantly different from the socket group (P <0.05). Histologic analysis revealed that the socket group had 35% ± 16% vital bone, and the overlay group had 40% ± 16% (P >0.05). Conclusions: The overlay treatment significantly prevented loss of ridge width and preserved or augmented the buccal contour. The socket and overlay groups healed with a high percentage of vital bone.     

Synthetic polymeric barrier membrane associated with blood coagulum,human allograft,or bovine bone substitute for ridge preservation: a randomized,controlled, clinical and histological trial

During the normal healing process, an extraction site may lose significant bone volume, making implant placement problematic. Quantitative evaluations of the amount of bone maintained by socket preservation with various materials are limited. The objective of this study was to evaluate, both clinically and histologically, the extent of alveolar bone preservation by blood coagulum (BC) and the potential additional benefits of bone allograft material (AL) versus the state-of-the-art bovine bone mineral (BB), covered by a polyethylene glycol (PEG) barrier, in extraction socket grafting procedures. Adult patients (n = 32) with single-rooted teeth indicated for extraction were treated (45 sites). After atraumatic extraction, the sockets were filled with BC, AL, or BB and covered with a synthetic PEG barrier membrane. Changes in bone height and width were measured clinically and the amount of bone formed and residual graft particles were measured histologically after 6 months. Changes in ridge width at 6 months were ?1.5 mm for AL versus ?2.5 mm for BB and ?2.3 mm for BC. New bone formation amounted to 47.8%, 33.3%, and 28.2% at BC-, AL-, and BB-treated sites, respectively. Using AL with the PEG barrier preserved the ridge width at 6 months better than BB or BC and resulted in similar amounts of bone histologically to BB.     

上前牙美学区即刻种植的研究现状

在牙齿拔除的同时将种植体立即植入新鲜拔牙窝的种植方式,其具有减少手术次数和整体治疗时间、充分利用现有骨量、具有理想的美学效果等优点。然而,即刻种植同样存在本身固有的缺点,由于拔牙窝的存在,创口的关闭较困难;由于种植体的尺寸与拔牙窝不匹配,较难达到良好的初期稳定性;并且存在软组织退缩的风险。本文就上前牙美学区即刻种植的成功率、适应证及其扩展、手术要求、并发症及其防治等方面作一综述。文献复习结果表明,即刻种植的5年成功率高于95%。其适应证包括:拔牙窝完整;唇侧骨壁厚度至少为1mm;厚龈生物型;种植位点无急性感染;根尖区足够骨量以提供良好初期稳定性。同时近年来随着种植外科技术的改良和骨替代材料性能的改善,即刻种植已成为口腔种植诊疗中的常规手段之一,并且其适应证有进一步扩大趋势。但其也有并发症,包括种植体植入位置不佳,牙龈退缩造成美学效果欠佳。此外即刻种植即刻修复和常规负荷表现出相似的结果,并有利于获得更好的美学效果,但关于即刻种植软组织美学的长期稳定性和患者满意度尚需进一步研究。     

珊瑚骨粉复合组织补片进行拔牙位点保存的临床研究

目的探讨使用珊瑚骨粉复合组织补片进行拔牙位点保存的临床效果。方法选取自2012年12月至2014年2月期间在武警总医院口腔种植科门诊采用微创技术拔除磨牙的患者45例,试验组20例,拔牙窝内植入珊瑚骨粉,组织补片覆盖表面关闭拔牙窝;对照组25例,拔牙后常规处理。1、3、6个月复诊,观察拔牙窝愈合情况。拔牙前及拔牙6个月后进行口内取模灌注石膏模型并拍摄X线牙片,分别测量牙槽嵴的高度和宽度,使用配对t检验分别对两组拔牙前至6个月期间牙槽嵴高度、宽度的变化进行统计学分析,使用两独立样本的t检验进行两组间牙槽嵴高度、宽度变化的比较,P〈0.05为差异具有统计学意义。结果临床观察除有一例组织补片脱落外,试验组其他拔牙窝均愈合良好,牙槽骨丰满,牙龈色、形、质与邻牙协调;而对照组牙槽嵴吸收、萎缩,高度降低、宽度显著缩小。统计学分析试验组牙槽嵴高度和宽度的改变无显著的统计学差异（P〉0.05）;对照组的上述改变具有统计学差异（P〈0.05）。两组间牙槽嵴高度、宽度的变化相比,二者间的差异均具有统计学意义（P〈0.05）。结论珊瑚骨粉复合组织补片有效保存了进行种植牙修复所必需的骨量,是进行拔牙后位点保存术的合适材料。     

Foreign body granuloma following placement of hard tissue replacement material: a case report

The placement of grafting material in extraction sites for ridge preservation is an increasingly common practice among clinicians. This is a case report of a patient presenting with a symptomatic, foreign body granuloma following the placement of hard tissue replacement (HTR) in extraction sockets. The surgical specimen revealed numerous histiocytes and foreign body type giant cells. The grafting material was surgically removed and the patient's symptoms were alleviated. Although biocompatibility of HTR has previously been shown, specific applications may be contraindicated or some patients may exhibit sensitivity to this material.     

Preservation of the ridge and sealing of the socket with a combination epithelialised and subepithelial connective tissue graft for management of defects in the buccal bone before insertion of implants: a case series

Defects in the layer of buccal bone lead to its loss after tooth extractions. This requires hard tissue grafting before implants can be put in place. The aim of this study was to evaluate the stability of hard tissue grafts inserted at the same time as the teeth were extracted. Teeth had to be extracted because of defects in the buccal bone. Extractions were combined with preservation of the ridge using autogenous and artificial bone. A combination epithelialised and subepithelial connective tissue graft was used to seal the socket. Wound healing was assessed and the width of the alveolar crest was measured after hard tissue grafting and during insertion of the implants. We studied 39 patients (20 female, 19 male, mean (SD) age 41 (7.9) years) who had 43 teeth extracted together with preservation of the ridge. One patient failed to attend for placement of the implant. Thirty-nine implants were inserted 5.3 (0.4) months after preservation of the ridge. Two patients developed partial necrosis of the combination graft, but in all other cases primary wound healing was uneventful. In three cases the bone grafts failed to consolidate. The mean (SD) width of the alveolar crest was after bone grafting 6.80 (1.20) mm and during insertion of implants 5.65 (1.50) mm; the mean resorption of the bone grafts was 1.2 (1.1) mm. We conclude that bone grafting to rebuild buccal alveolar defects at the same time that the tooth is extracted, combined with a soft tissue graft to seal the socket, showed promising results and could be an alternative treatment to delayed hard tissue grafting.