Mauricio G.
Araújo
Jan Lindhe
Authors’ affiliations:
Mauricio G. Araújo, Department of Dentistry,
State University of Maringá, Parana, Brazil
Jan Lindhe, Institute of Odontology, The
Sahlgrenska Academy at the University of
Gothenburg, Gothenburg, Sweden
Correspondence to:
M. G. Araújo
Department of Dentistry
State University of Maringá
Rua Silva Jardim, 15/sala 03
87013-010
Maringá-Paraná-Brazil
Tel.: þ 55 44 3224 6949
Fax: þ 55 44 3224 6444
e-mail: odomar@hotmail.com
Date:
Accepted 7 December 2008
To cite this article:
Araújo MG, Lindhe J. Ridge alterations following tooth
extraction with and without flap elevation. An
experimental study in the dog.
Clin. Oral Impl. Res. 20, 2009; 545–549.
doi: 10.1111/j.1600-0501.2008.01703.x
c 2009 The Authors. Journal compilation 
 c 2009 John Wiley & Sons A/S
Ridge alterations following tooth
extraction with and without flap
elevation: an experimental study
in the dog
Key words: bone resorption, extraction, flapless surgery
Abstract
Background: Different approaches were advocated to preserve or improve the dimension
and contour of the ridge following tooth extraction. In some of studies, socket ‘flapless
extraction’ apparently had a successful outcome.
Aim: The objective of the present experiment was to compare hard tissue healing
following tooth extraction with or without the prior elevation of mucosal full-thickness
flaps.
Material and methods: Five mongrel dogs were used. The two second mandibular
premolars (2P2) were hemi-sected. The mesial roots were retained. By random selection the
distal root in one side was removed after the elevation of full-thickness flaps while on the
contralateral side, root extraction was performed in a flapless procedure. The soft tissue
wound was closed with interrupted sutures. After 6 months of healing, the dogs were
euthanized and biopsies were sampled. From each experimental site, four ground sections –
two from the mesial root and two from the healed socket – were prepared, stained and
examined in the microscope.
Results: The data showed that the removal of a single tooth (root) during healing caused a
marked change in the edentulous ridge. In the apical and middle portions of the socket site
minor dimensional alterations occurred while in the coronal portion of the ridge the
reduction of the hard tissue volume was substantial. Similar amounts of hard tissue loss
occurred during healing irrespective of the procedure used to remove the tooth was, i.e.
flapless or following flap elevation.
Conclusion: Tooth loss (extraction) resulted in marked alterations of the ridge. The size of
the alveolar process was reduced. The procedure used for tooth extraction – flapless or
following flap elevation – apparently did not influence the more long-term outcome of
healing.
Following tooth extraction the alveolar In a recent experiment in the dog, Fickl
process will undergo a change (e.g. Pietro- et al. (2008) showed that tooth extraction
kovski & Massler 1967; Schropp et al. after the elevation of mucosal flaps (to
2003; Araújo & Lindhe 2005). Thus, the disclose the marginal bone) during a 3-
bundle bone will disappear (Cardaropoli month period of healing caused more
et al. 2003) and the height of the buccal (about 14%) soft and hard tissue reduction
wall of the socket will reduce (Schropp than a ‘flapless’ tooth removal. Similar
et al. 2003; Araújo & Lindhe 2005; Araújo findings were reported by Blanco et al.
et al. 2008). (2008) from a study in beagle dogs. The
545
Araújo & Lindhe . Flapless tooth extraction
Fig. 1. Clinical photograph illustrating the distal socket of a second mandibular premolar following flapless (a)
and flap elevation (b) tooth extraction. Note that in the flap elevation procedure (b) the flap was elevated so that
at least 3 mm of the coronal portions of the buccal and lingual surfaces of the alveolar process were exposed.
authors stated that ‘flapless immediate
implant surgery’ produced somewhat less
buccal bone plate resorption than when
mucosal flaps were elevated in conjunction
with tooth extraction and implant installa-
tion.
The objective of the present experiment
was to assess alveolar ridge alterations that
had occurred 6 months after tooth extrac-
tion with or without flap elevation.
Material and methods
The ethical committee of the State Uni-
versity of Maringá approved the research
protocol. Five beagle dogs about 1-year-old
and weighing between 12 and 14 kg each
were used. During the surgical procedures,
the animals were anesthetized with intra-
venously administered Ketamin (10%,
8 mg/kg, Agener União, São Paulo, Brazil).
The second premolars on both sides of
the mandible were hemi-sected with the
use of fissure burs. The canal of each
mesial root was reamed and filled with
gutta-percha.
Pocket incisions were made along the
distal root of the second premolar in one
randomly selected side of the mandible
(flap group) and buccal/lingual full-thick-
ness flaps were elevated. Flap elevation
was extended to a level beyond the muco-
gingival line and disclosed the alveolar crest
and the marginal 3–4 mm of the buccal and
lingual bone walls. The bone tissue was
exposed for about 15 min. No incisions or
546 | Clin. Oral Impl. Res. 20, 2009 / 545–549
flap elevations were made in the contra-
lateral side (flapless group).
The distal roots were carefully removed
with the use of elevators and the extraction
wound in both sides was closed with inter-
rupted sutures (Fig. 1a and b). The sutures
were removed after 10 days.
The animals were placed in a plaque
control regimen that called for tooth clean-
ing once every second day.
After 6 months of healing, the dogs were
euthanized with an overdose of Ketamin
and perfused with a fixative containing a
mixture of 5% glutaraldehyde and 4%
formaldehyde (Karnovsky 1965). The
mandibles were removed and placed in
the fixative. Each experimental site, in-
cluding the mesial root and the distal
socket area, was dissected using a diamond
s
saw (Exact Apparatebeau, Norderstedt,
Hamburg, Germany). The tissues were
processed for ground sectioning according
to the methods described by Donath &
Breuner (1982) and Donath (1988). The
samples were dehydrated in increasing
grades of ethanol and infiltrated with Tech-
s Histological observations
novit 7200 VLC-resin (Kulzer, Frie-
drichrsdorf, Germany), polymerized and
sectioned using a cutting–grinding unit
s
(Exact Apparatebeau).
From each experimental site, four sec-
tions – two from the mesial root and two
from the healed socket – were prepared.
The sections were cut in the buccal-lingual
plane and were sampled from the central
area of either the root (tooth) or the socket
site. The sections were reduced to a thick-
c 2009 The Authors. Journal compilation 
 c 2009 John Wiley & Sons A/S
ness of about 20–30 mm by microgrinding
and polishing and stained in toluidine blue
or Ladewig’s fibrin stain (Donath 1993).
The histological examination was per-
s
formed in a Leitz DM-RBE microscope
(Leica, Wetzlar, Germany) equipped with
s
an image system (Q-500 MC , Leica).
Each histological section was examined
using a methodology previously described
in detail by Araújo et al. (2008). Briefly, the
outline of the alveolar process obtained at
the tooth site was projected over the sec-
tion using the apex of the mesial root as the
reference level. Three equally high por-
tions, apical, middle and coronal, were
outlined. The area occupied by each of
these three portions of the alveolar process
was measured with a cursor and expressed
in mm2. The relative alteration of the size
of the three portions of the alveolar process
that had occurred in each dog after tooth
extraction and healing was estimated by
subtracting the value obtained at the ex-
traction site from the corresponding value
at the adjacent tooth site.
Furthermore, at the buccal and lingual
aspects of the tooth sites the distances
between the cementum–enamel junction
(CEJ) and the apical cells of the junctional
epithelium (aJE) and the bone crest (BC)
were measured.
The mean values and standard deviations
were calculated using the dog as the statis-
tical unit. Differences between groups were
evaluated using Student’s t-test.
Results
All experimental sites healed uneventfully.
After 6 months, the mucosa covering the
edentulous ridge and the gingival tissues at
adjacent teeth appeared to be clinically
healthy.
Tooth sites
In the second premolar region, the base of
the mandible occupied more than 50% of
the entire cross-section area (Fig. 2). The
medial mental foramen was located in the
buccal bone wall and often close to the apex
of the mesial root. The lingual bone wall of
the alveolar process was markedly wider
than the corresponding buccal wall.
Furthermore, the crest of the buccal bone

wall was consistently located apical of the
lingual crest.
The gingival margin in the flapless as
well as in the flap group was consistently
located coronal to the CEJ. The gingival
connective tissue was virtually free from
infiltrates of inflammatory cells.
At the buccal surface of the mesial root
in the flapless group, aJE were located at
the CEJ (Fig. 3). The most coronal portion
of the buccal bone wall was comprised of
mainly bundle bone. In the flap group, aJE
was located apical of CEJ and the most
coronal portion of the BC exhibited signs of
resorption (Fig. 4).
In the flap group, aJE (Table 1) were
located on the average 0.2  0.1 mm (buc-
cal) and 0  0 mm (lingual) apical of the
CEJ, while in the flapless group the corre-
sponding dimensions were 0.07  0 mm
(buccal) and 0  0 mm (lingual). In other
words, at the buccal surface of the teeth in
Fig. 2. Microphotograph of a buccal-lingual section
representing the second mandibular premolar and
the surrounding tissues. Note that the base of the
mandible occupied a larger area than the alveolar
process. B, buccal bone wall; L, lingual bone wall.
Ladewig fibrin stain; original magnification  7.
c 2009 The Authors. Journal compilation 
 c 2009 John Wiley & Sons A/S
the flap group, there was some loss of
connective tissue attachment. At the lin-
gual aspect, there was no sign of attach-
ment loss in any of the groups.
At the buccal aspect of the teeth in the
flap group, the distance between CEJ and the
BC was 1  0.1 mm while the correspond-
ing value for the flapless group was signifi-
cantly smaller (0.7  0.2 mm; Po0.05).
Extraction sites
The overall histological features of the
edentulous sites were similar in the flap-
less and the flap groups (Figs 5 and 6).
Thus, in all specimens, a thick, well-ker-
atinized mucosa covered the healed socket.
The connective tissue was devoid of in-
flammatory cell infiltrates but was charac-
terized by the presence of a dense network
of collagen fibers.
The entrance of all socket sites was
‘closed’ by a hard tissue bridge of varying
dimensions that connected the buccal and
Fig. 3. Microphotograph of the buccal bone crest of
the mesial root of a second premolar in the flapless
group. Note that the apical cells of the junctional
epithelium were located at the cementum–enamel
junction. BC, bone crest. Ladewig fibrin stain;
original magnification  50.
Table 1. Results of the histometric measurements (expressed in mm) performed at the
buccal and lingual aspects of the mesial roots; tooth sites
Buccal
Flapless Flap
CEJ–aJE 0.07  0.1 0.2  0.1
CEJ–BC 0.7  0.2n 1.0  0.1
n
Po0.05.
Mean  (SD).
aJE, the apical cells of the junctional epithelium; BC, bone crest; CEJ, cementum–enamel junction.
Araújo & Lindhe . Flapless tooth extraction
lingual crests. The newly formed bone of
the bridge in the socket entrance included
both woven and lamellar bone. The middle
and apical portions of the alveolar process
were occupied by bone marrow and small
amounts of lamellar bone.
The comparison of the buccal-lingual
cross-section area of the tooth and the
extraction sites revealed that the removal
of the tooth after 6 months had caused a
slight reduction in the overall dimension of
the ridge (Table 2). Thus, in the flap group
the edentulous ridge was on average
14  6% smaller than the alveolar process
of the corresponding tooth site. The
equivalent reduction in the flapless group
was 17  16%. This difference was not
statistically significant. A more detailed
examination revealed that the reduction
in the apical portion was 5  3% (flap)
and 6  5% (flapless), respectively, while
Fig. 4. Microphotograph of the buccal bone crest of
the mesial root of a second premolar in the flap
group. Note that the apical cells of the junctional
epithelium were located apical of the cementum–
enamel junction and the most coronal portion of the
bone crest exhibited signs of resorption. BC, bone
crest. Ladewig fibrin stain; original magnification
 50.
Lingual
Flapless Flap
00 00
0.8  0.2 0.7  0.2
547 | Clin. Oral Impl. Res. 20, 2009 / 545–549
Araújo & Lindhe . Flapless tooth extraction
Fig. 5. Microphotograph of a buccal–lingual section
representing the edentulous site in the flapless group.
Note that the center of the alveolar ridge is occupied
mainly by bone marrow. Furthermore, the cortical
crest slopes in the apical direction from the lingual to
the buccal wall of the ridge. B, buccal bone wall; BM,
basal body of the mandible; L, lingual bone wall.
Ladewig fibrin stain; original magnification  7.
the corresponding reduction in the middle
portion was 14  11% (flap) and 9  5%
(flapless). In the marginal portion of the
edentulous ridge, there was a marked re-
duction of the dimension in both groups.
This amounted to 35  15% in the flap
and 35  25% in the flapless group. This
difference between the groups was not
statistically significant.
Discussion
The present experiment confirmed that the
removal of a single tooth (root) during
healing caused a marked change in the
edentulous ridge. Thus, in the apical and
middle portions of the socket site, minor
dimensional alterations occurred while in
the coronal portion of the ridge, the reduc-
tion of the hard tissue volume was sub-
stantial. It was also observed that similar
amounts of bone loss occurred during heal-
ing irrespective of the procedure used for
tooth removal, i.e. flapless or following
548 | Clin. Oral Impl. Res. 20, 2009 / 545–549
Fig. 6. Microphotograph of a buccal–lingual section
representing the edentulous site in the flap group.
Note that the profile of the ridge has many features
in common with that of the flapless group. B, buccal
bone wall; BM, basal body of the mandible; L,
lingual bone wall. Ladewig fibrin stain; original
magnification  7.
Table 2. Mean  (SD) relative alteration
(% change in comparison with the tooth
site) of the surface area (mm2) of the over-
all and, coronal and middle and apical
thirds of the edentulous alveolar process
Area Flapless site (%) Flap site (%)
Overall  17  16  14  6
Coronal  35  25  35  15
Middle 9  5  14  11
Apical 6  5 5  3
 A relative decrease of the cross-section area.
flap elevation. Moreover, the buccal aspect
of the mesial tooth portion in the flap group
had undergone more attachment and bone
loss than was the case in the corresponding
site of the flapless group.
The present findings are in agreement
with data published by e.g. Pietrokovski &
Massler (1967), Schropp et al. (2003) and
Barone et al. (2008) showing that the loss
(extraction) of teeth will result in loss of
tissue volume in the edentulous ridge and
that tissue loss is more pronounced from the
buccal than from the lingual/palatal aspect.
c 2009 The Authors. Journal compilation 
 c 2009 John Wiley & Sons A/S
The main observation made in the cur-
rent study, however, was that similar
amounts of hard tissue loss occurred after
the teeth (roots) had been removed in a
flapless as against a flap elevation proce-
dure. Thus, in the coronal third of the
edentulous ridge, both types of extraction,
after 6 months of healing, had resulted in a
35% reduction of the hard tissue dimen-
sion. This finding may be interpreted as
not being in agreement with data published
recently (e.g. Blanco et al. 2008; Fickl et al.
2008). Fickl et al. (2008) studied tissue
alterations after tooth extraction performed
in either a flapless or a flap procedure in the
beagle dog. Healing was studied 2 and 4
months after tooth extraction using volu-
metric measurements made on casts. In
other words, the measurements included
both soft and hard tissue components. The
authors concluded ‘. . .. leaving the perios-
teum in place decreases the resorption rate
of the extraction socket’. A more detailed
analysis of the data illustrated that both
extraction techniques resulted in loss of
tissue volume, but also that the model
used in the experiment did not distinguish
between soft and hard tissue components.
Blanco et al. (2008) examined ridge altera-
tions following immediate implant place-
ment in fresh extraction sockets in a dog
model. The teeth were removed either in a
flapless or in a flap elevation procedure. In
biopsies obtained after 3 months of healing
following implant (Straumannt implant
System) installation it was observed that
the buccal BC was located on average
4.13 mm (flap) and 3.62 mm (flapless)
from the shoulder of the device. The corre-
sponding distances on the lingual aspect
were 3.13 mm (flap) and 3.17 mm (flap-
less). In this context it should be observed
that the ‘abutment’ portion of the Strau-
mannt implant is 2.8 mm high (the dis-
tance between shoulder and the marginal
border of the SLA surface). In other words,
the difference between the flapless and the
flap group after 3 months amounted to
about 0.5 mm at the buccal aspect, while
on the lingual aspect there was virtually no
difference. One important difference be-
tween the current study and the experi-
ment by Blanco et al. (2008) is the length of
the healing period, i.e. 6 vs. 3 months. It
has been shown by e.g. Schropp et al.
(2003) that dimensional changes following
tooth extraction are not completed after

3 months but that between 3 and 12
months additional resorption and reduction
will occur. The data from the present
experiment therefore suggest that the 0.5-
mm difference between the flap and the
flapless group observed in the Blanco et al.
(2008) study may disappear after longer
healing periods.
It is well established in the periodontal
literature that the elevation of a full-thick-
ness flap (muco-periostal flap) to gain ac-
cess to the root surface for debridement
may cause some loss of attachment and
resorption of bone (for a review, see Tavti-
gian 1970; Heitz-Mayfield et al. 2002).
The extent of reduction of the supporting
bone is apparently related to the thickness
of the bone at the surgical site (Wood et al.
1972; Karring et al. 1975; Yaffe et al. 1994).
Thus, the thinner the bone wall, the
greater becomes the crestal resorption. In
a recent study in the beagle dog from our
laboratory (Araújo et al. 2005) it was de-
monstrated that flap elevation without in-
tentional root surface instrumentation
caused about 1-mm vertical loss of the
thin buccal wall while in the thick lingual
wall the corresponding loss was only
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