SYSTEMATIC REVIEW

Root submergence technique as a partial extraction therapy to

preserve the alveolar ridge tissues: A systematic review and
appraisal of the literature
Jonathan Du Toit, BChD, MSc, MChD (OMP), FCD(SA) OMP, PhD,a Maurice Salama, DMD,b
Howard Gluckman, BDS, MChD (OMP), PhD,c and Katalin Nagy, DDS, PhDd

The loss of alveolar ridge vol- ABSTRACT

ume as a result of tooth Statement of problem. As socket grafting with commercially available biomaterials has become
extraction has been noted in popular, reports of the root submergence technique for ridge preservation have decreased. A
the literature since the 1960s.1-3 systematic review of this partial extraction therapy is lacking.
The full extent of why this
Purpose. The purpose of this systematic review was to review the root submergence technique as
happens is still not entirely well as critically appraise the available data.
understood,4 with a widely
accepted explanation for the Material and methods. A review was carried out that observed the Participant, Intervention,
Comparison, Outcomes (PICO) strategy and the Preferred Reporting Items for Systematic Reviews
loss relating to factors that and Meta-Analyses (PRISMA) guidelines. The focused question was “What are the outcomes of
include traumadthe extrac- the different methods to submerge tooth roots for ridge preservation?” Medical subject headings
tion socket as a wound sees (MeSH) terms that related to the root submergence technique were searched in PubMed/
upregulation of inflammatory MEDLINE, Scopus, and the Cochrane Library databases.
processes, resultant activation Results. A total of 7709 abstracts and study titles were individually screened from the initial search
of osteoclastic activity, resor- results. After reviewing the full-text articles and applying the selection criteria, the final included
ption of the extraction socket, search results totaled 47 full-text articles for in-depth review. In 10 animal studies, 258 roots
and an eventual healing that were studied in 34 dogs and 7 monkeys. Histological data confirmed that coronal bridging (bone
typically results in loss of tis- or cementum growth over the cut root) was a common outcome. Of the vital roots submerged,
sue volume and architecture. 5 the majority maintained their vitality. In 37 human studies, 475 roots were submerged and
reported on. Subjective ridge preservation was often reported. Among the adverse healing
Second, bundle boned
outcomes, exposure of the root through the mucosa was the most common. Nonetheless, in
removal of the tooth results in animals, 86.8% of roots remained submerged; in humans, 74.7%.
periodontal ligament (PDL)
fibers being severed, loss of Conclusions. Root submergence is an established technique for ridge preservation. Exposure is a
common complication, and correct technique may be key to its prevention. Further research of
Sharpey fibers that insert into
this partial extraction therapy is encouraged. (J Prosthet Dent 2023;130:187-201)
bundle bone, and a subse-
quent loss of the mineralized
bone layer that lines the alveolus.4-6 At the buccal or The emphasis on ridge preservation has focused on
facial aspect, the bone plate may consist entirely of preparing a future implant site,7 that is, grafting the
bundle bone.6 extraction socket typically with a bone substitute material

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
a
Private practice, Johannesburg, South Africa.
b
Clinical assistant Professor of Periodontics, University of Pennsylvania, Philadelphia, Pa; and Clinical assistant Professor of Periodontics, Medical College of Georgia,
Augusta, Ga; Private practice, Atlanta, Ga.
c
Private practice, Cape Town, South Africa.
d
Head of Oral Surgery, Faculty of Dentistry, University of Szeged, Szeged, Hungary.

THE JOURNAL OF PROSTHETIC DENTISTRY 187

188
Clinical Implications
Resorption of the postextraction alveolar ridge may
lead to treatment complications. Retaining part of
the tooth root may help preserve the ridge.
has been widely popularized as an effective prevention of
volume loss.8 These techniques are not new, and reports
date back to the 1960s and 1970s. Sockets back then were
back grafted experimentally with acrylic resin, plaster of
Paris, autogenous costochondral cartilage, and hydrox-
ylapatite.9,10 In recent decades, the use of many combi-
nations of materials and techniques has been evaluated,
with results frequently showing that grafted sockets heal
with less volume loss than sockets without grafting.11
The topic is, however, complex, and grafted sockets are
usually used to prepare a site to receive a dental implant.
However, how pontic sites and extraction sites adjacent
to dental implants should best be preserved is less clear.
The first root submergence techniques were re-
ported9,12-22 at around the same time as the first socket
grafting techniques were introduced. Root submergence
likely evolved from the overdenture technique, but with
the tooth decoronated and covered beneath oral mucosa.
The need for this evolution in technique was likely
because of overdenture abutment teeth being susceptible
to dental caries and periodontal disease.23 The first
report of the root submergence technique was probably
by Poe et al12 in 1971 and is today part of the collective
treatment concept known as the partial extraction ther-
apies.24,25 The indications and rationale are numerous.
Originally intended for complete removable dentures,
the root submergence technique at a pontic site also
maintains ridge volume and esthetics for fixed partial
denture treatmentdboth tooth- and implant-sup-
ported.26,27 The most significant benefit is likely the
support of ridge tissues by a root submerged adjacent to
or between multiple implants.26 This partial extraction
therapy has been somewhat forgotten today. The aim of
this study was to systematically review studies published
on root submergence techniques, critically appraise the
available data, and better inform the clinician with regard
to the performance and pitfalls of this treatment option.
The null hypothesis was that insufficient evidence exists
to support the root submergence technique as a treat-
ment option to preserve the alveolar ridge.
MATERIAL AND METHODS
The Population, Intervention, Comparison and Out-
comes (PICO) format and Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA)
guidelines govern accurate conformity of systematic
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 130 Issue 2
reviews.28,29 As too few studies on the root submergence
technique with a comparison control group have been
published, not all the components of these criteria could
be satisfied. Instead, a concise review of all the available
literature was made with an explicit focus on scrutinizing
the data. In part, the PICO question as per Needleman28
was addressed and structured the methodology of this
review. However, in keeping with systematic review
convention, the established PRISMA guidelines were
observed wherever possible.
The PICO question was "What are the outcomes of
the different methods to submerge tooth roots for ridge
preservation?” The population included studies that
investigated root submergence techniques in both ani-
mals and human participants. Interventions included
root submergence techniques as investigated in this re-
view and are defined as the intentional partial extraction
of a tooth such that a portion of the root remained in situ
within its alveolus, free of disease, and fully submerged
beneath healed mucosa for the purpose of ridge preser-
vation. This generally requires sectioning the tooth crown
(decoronation), with or without additional corono-apical
reduction of the tooth root. The root may be vital, or
endodontically treated. The general purpose of sub-
merging the root is to achieve complete mucosal healing
and coverage over it, to maintain the root without pa-
thology, and to preserve the alveolar ridge tissues in lieu
of fully extracting the tooth.
The comparison inclusion criterion for solely selecting
randomized controlled studies was waived for this review
because only 2 studies had a control group.16,30 The
outcomes of interest component was structured. The
primary outcome was ridge preservation achieved or
limitation of alveolar ridge atrophy reported. Secondary
outcomes included positive outcomes reported: mucosal
coverage maintained, radiographic or histologic evidence
of coronal bridging (coronal bone or hard-tissue healing
over the root), and adverse healing outcomes reported:
root exposure, root exfoliation, infection, alveolar bone
loss, loss of vestibular depth, pain and discomfort, root
resorption, and need for additional interventions (such as
endodontic treatment, repeat submergence, and extrac-
tion). Nevertheless, root resorption may not be an
adverse healing outcome per se. Replacement resorption
of a root portion in partial extraction therapy by bone
deposition is likely a positive outcome.
With regard to article eligibility criteria, all studies
(animal and human) reporting on the submergence of
tooth roots for ridge preservation were considered. The
data were histological, radiographic, and clinical. Many
reports documented roots submerged after trauma, but
these were excluded from this review, as trauma with
alveolar and root fracture may confound the results.
Studies reporting on mandibular third molar roots sub-
merged to prevent inferior alveolar nerve injury
Du Toit et al
August 2023 189

Identification
Results identified through databases
searching (MEDLINE/PubMed,
Scopus, Cochrane)
n=7709)

Screening
Results screened according to Records excluded
studies selection criteria (n=7709) (n=7645)
Identification

Additional records
Final full text articles evaluated for excluded (results not
eligibility (n=64) complying with
selection criteria)

Additional results
Included

Final full-text articles included in the included from full

review (n=47) text articles’
reference lists (n=4)

Figure 1. Search strategy.

(coronectomy) were also determined too heterogenous
from the general pool of root submergence techniques for
ridge preservation data and, thus, were not considered in
this review. Numerous studies also investigated sub-
merged roots associated with infrabony periodontal de-
fects for the purpose of experimental periodontal
regeneration. Valuable data could be derived from these
studies. Cook et al31 in 1977 reported on 12 submerged
roots, noting the ridge preservation potential, and not all
roots had periodontal defects. However, heterogeneity in
technique led to exposure in other studies, which would
confound the current review’s results.32 Thus, these
studies were also omitted. Apart from these excluded
studies, all methods of root submergence, flap manage-
ment, endodontic management (both vital and
endodontically treated roots), and periods of follow-up
were included. Studies published at any date were
considered. Archived historic data were considered only
if the full-text article (in English) could be analyzed.
The search strategy comprised data searches in the
National Library of Medicine (MEDLINE-PubMed), Sco-
pus, and Cochrane databases. The medical subject head-
ings (MeSH) terms searched and their respective results
were “submergence+root”=498 results; “submerged+-
root”=691 results; “submerged+tooth+root”=125
results; “retained+tooth+root”=1684 results; “vital+
retained+root”=59 results; “root+bank”=667 results;
“root+retention”=2984; “partial+odontectomy”=16 re-
sults; “tooth+coronectomy”=126 results; “tooth+
root+coronectomy”=71 results; “decoronation”=542
results; “root+ridge+preservation”=135 results; “sub-
mucosal+roots”=28 results; “submerged+over+
denture”=66 results; “submucosal+over+denture”=17
results. The MeSH terms “overdenture” and “over-
lay+denture” combined produced 8445 search results, were
too heterogenous, and included implant-supported
overdentures. These were also omitted.
RESULTS
The electronic searches produced a total of 7709 re-
sults, the titles and abstracts of which were screened.
After applying the selection criteria, excluding non-
applicable results, and additionally reviewing the
reference lists of all the selected full-text articles, 47
full-text articles were selected for detailed analysis. Of
these, 10 studies were conducted in animals and 37
in humans (Fig. 1).
A total of 258 roots were studied in 34 dogs and 7
monkeys across 10 studies from 1971 to 1984
(Table 1).12,14,15,17,19,21,33-36 Histological examination was
performed in all animal studies. Among the vital

Du Toit et al THE JOURNAL OF PROSTHETIC DENTISTRY

190 Volume 130 Issue 2

Table 1. Combined data for all animal studies reporting on root submergence technique (RST) for ridge preservation
Adverse Outcomes Positive Outcomes
S. No. Authors Cohort Decoronation Method Closure Method Outcome Types Reported Reported
1 Poe et al,  3 dogs  Decoronation by  Advanced flaps, split-  Clinical  None reported  Root vitality
197112  24 roots “dental burs and thickness, vertical release  Radiographic maintained
total bone file” incisions  Histologic  Contiguous
 Up to 120  Reduced to blood supply
days healing bone crest between canal
 Vital roots, no and CT
endodontic
treatment
2 Whitaker  3 monkeys  Decoronation by  Advanced flaps,  Clinical  Adverse healing  8 of 12 roots
and  Upper and mallet and chisel vertical release incisions,  Histologic outcomes due to submerged at
Shankle, lower  Reduce to periosteal release mallet and chisel 25 days
197417 anterior sites, bone crest incisions fracture  6 of 8 retained
12 roots  Both vital roots  21 of 36 roots vitality
each, 36 and endodontic exposed  Bone and
roots total treated roots cementum
 Up to 25 growth over
days healing some roots
3 Johnson  2 monkeys  Decoronation by  Advanced flaps with  Clinical  Exposure at 1 of  Vitality
et al,  12 roots high-speed, irri- periosteal release  Histologic 24 roots maintained in
197414 each, 24 gated bur incisions  Root resorption all roots
roots total  Reduced to at 2 of 24 roots  All roots
 Up to 12 mo bone crest showed
follow-up  Facial root partial or
contoured to complete
ridge calcified tissue
 Vital roots, no growth over
endodontic roots
treatment
4 Levin et al,  8 dogs  Decoronated by  Advanced flaps  Clinical  Exposure at 1  Total bone
197415  16 maxillary high-speed, irri-  No description of  Histologic root coverage at 1
roots total gated bur achieving tension-free  Cyst formation at root
 Up to 29  Reduced to flap closure 3 roots not  Bone coverage
weeks of bone crest reduced to bone and new PDL
follow-up  Endodontic crest tissue at 1 root
treatment  Abscess at 2  Partial bone
roots coverage at 2
 Root resorption roots
at 3 roots  15 of 16 roots
 Apical remained
granulation at 1 submerged
root
 Migration of 1
root
5 Reames  2 monkeys  Sectioned with  Advanced flaps,  Clinical  2 roots exposed  Bone growth
et al,  12 roots high-speed irri- vertical release incisions  Radiographic over roots
197519 each, 24 gated rotary bur  Histologic reduced below
roots total  Reduced crest
 5 mo follow- 2-3 mm below
up bone cresta
 Endodontic
treatment
6 Plata and  3 dogs  “Amputated with  Advanced flaps  Clinical  2 failures:  Bone growth
Kelln,  12 bur” (no further  No description of  Radiographic Incomplete over 8 of 12
197621 mandibular details reported) achieving tension-free  Histologic reduction to roots
roots total  Reduced 2 mm flap closure below bone crest  Regenerated
 Up to 12 below bone crest impeded bone PDL,
weeks  Vital roots, no coverage cementum
follow-up endodontic  Inflammation at reported
treatment these 2 roots,  Vitality
sinus tract at 1 maintained
root, early
exposure of 1
root, bone
resorption
 Resorption of
dentinb
(continued on next page)

submerged roots, 66 of 68 roots maintained their vitality In 2 studies35,36 by the same group that examined 92
(Fig. 2), confirmed by histology.12,14,17,21 Therefore, in the roots, the vitality of root canal tissues was not reported
4 studies submerging vital roots, 97% maintained vitality. and, thus, could not be commented on. Coronal bridging

THE JOURNAL OF PROSTHETIC DENTISTRY Du Toit et al

August 2023 191

Table 1. (Continued) Combined data for all animal studies reporting on root submergence technique (RST) for ridge preservation
Adverse Outcomes Positive Outcomes
S. No. Authors Cohort Decoronation Method Closure Method Outcome Types Reported Reported
7 O’Neal  4 dogs  Endodontic  Advanced flaps with  Clinical  3 roots  Total bone
et al,  16 roots treatment, root periosteal release  Radiographic developed cysts coverage over
197833 total extraction incisions, mattress  Histologic at extruded 7 roots
 Up to 3 mo  Sectioned with sutures endodontic  Partial bone
follow-up high-speed, irri- material coverage over
gated bur, 5 roots
outside the  (Subjective)
mouth Ridge
 Reimplanted 2-3 preservation
mm below bone
crest
8 Gound  4 dogs  Decoronation by  Advanced flaps with  Clinical  Resorption at all  Total bone
et al,  14 roots high-speed, irri- periosteal release  Radiographic roots coverage over
197834 total gated bur incisions, mattress  Histologic  Extruded coronal 1 root
 Up to 3 mo  Reduced 2 mm sutures endodontic  Partial bone
follow-up below bone crest sealer at all roots coverage over
 Endodontic 11 roots
treatment
9 Lambert  6 dogs  Decoronation by  Supraperiosteal recipient  Clinical  1 root exposed  43 of 44 Vital
et al,  44 high-speed, irri- bed and free gingival  Radiographic roots
198335 mandibular gated bur graft or split thickness  Histologic successfully
roots total  Reduced to bone skin graft submerged
 5 mo follow- crest  Bone growth
up  Vital roots, no over some
endodontic roots
treatment
10 Lambert  6 dogs  Decoronation by  Supraperiosteal recipient  Clinical  6 roots exposed  42/48 Vital
and  48 high-speed, irri- bed and split thickness  Radiographic roots
Marquard, mandibular gated bur skin graft  Histologic successfully
198436 roots total  Reduced to bone  Supraperiosteal recipient submerged
 Up to 12 mo crest bed, mucosal envelope,  Partial
follow-up  Vital roots, no and dermal graft cementum
endodontic coverage over
treatment some roots

CT, connective tissue; PDL, periodontal ligament. aReames et al, 1975.19 Images in report show some roots at bone crest. bResorption of root replaced by bone may not be adverse healing
outcome.

(hard tissuedbone, cementum, or secondary dentin

healed over of the cut root portion) was reported in 9 of
10 studies14,15,17,19,33-36 (Fig. 3).
Exposure of root (perforating through the overlying
mucosa) was the most reported complication in 7 of 10
animal studies, 34 of 258 roots (Table 2). Approximately
86.8% of all roots in animal studies remained submerged.
Only 1 of 10 animal studies did not report complica-
tions.12 Almost all studies found complications, including
inflammation from the endodontic obturation material,
abscess and infection, root resorption, crestal bone
resorption, or root migration. More serious complications
(infection or roots requiring extraction) occurred in 16 of
258 submerged roots. Plata et al21 reported exposure at 1
Figure 2. Histologic section, monkey. Vital submerged canine root at 2
of 12 roots that developed a sinus tract. O’Neal et al33
weeks of healing. Note conjoining of root canal tissue with mucosal
reported that 3 of 16 roots developed histological
connective tissue. Image courtesy of Whitaker and Shankle, 1974.17
microcysts overlying extruded excess endodontic obtu-
ration material. Levin et al15 reported cysts or abscess
also in 3 of 16 roots. Whitaker and Shankle17 reported roots submerged beneath removable prostheses. Five
both vital and endodontically treated roots that became studies reported on roots submerged at pontic sites
exposed and presented with “severe inflammatory reac- beneath tooth-supported fixed partial dentures.27,56,58,59,63
tion” (9 of 36 roots). Three studies reported on implant-supported fixed partial
A total of 475 roots were submerged and reported on dentures.26,50,62 Of the human studies, 16 reported on
in 37 human studies from 1972 to 2015 submerged vital roots,18,30,37-39,42,43,45-49,52-54,57 13 re-
(Table 3).9,13,16,18,20,22,26,27,30,37-58,60-62 Most of these ported on submerged endodontically treated
studies comprised case series, with the majority involving roots,9,13,16,20,22,27,41,50,55,56,58-60,62,63 and 4 reported on

Du Toit et al THE JOURNAL OF PROSTHETIC DENTISTRY

192
Figure 3. A, Histologic section, monkey. Reported by original authors, (A) complete bone bridging over root, (B) “osteocementum” over cut root
surface. Image courtesy of Reames et al, 1975.19 B, Submerged dog premolar roots at 12 weeks. Radiographic evidence of coronal bridgingehard-tissue
growth over cut root surface (green arrows). Image courtesy of Plata and Kelln, 1976.21
both.26,44,61,51 One study did not specify.40 Only 2 studies
included data from control sites, 1 assessed extracted,
decoronated, and then reimplanted roots16 and the other
assessed ridge preservation from panoramic radio-
graphs,30 although this methodology appears to lack
precision.
In 3 studies,9,38,45 histological data were obtained
from roots that were electively removed subsequent to
exposure. These exposed roots displayed variable histo-
logical healing. Similar to the results in animal studies,
coronal bridging was noted in one study.38 Subsequent to
exposure, inflammatory cells were noted in the overlying
soft tissue, but the root canal tissue was confirmed to be
vital. In another study, inflammatory cells were also
noted in the histological examination of 4 of 8 exposed
roots.45 The third study reported only resorption of root
cementum.9
The primary outcome of variable ridge preservation
was subjectively reported in 20
studies.13,16,18,22,26,27,37,44,50,52,54,56-63 Only 1 study
attempted to report on objective ridge preservation.30
The authors of this review stated that vertical alveolar
bone loss evaluated on panoramic radiographs was not
an acceptable measurable objective. Radiographic ridge
preservation and/or coronal bridging of bone and
mineralized tissue was reported in 5 studies.9,30,38,41,51
Root exposure was the most reported complication in
18 of 37 human studies, 120 of 475 roots (25.3%)
(Table 2). In 9 of 37 studies, complications were not
reported,13,18,30,52,57,59,60,61,62 but they may have
occurred. Most studies found complications, including
histologic and radiographic root resorption, crestal bone
resorption, patient discomfort (under removable den-
tures), periapical pathology, progressive attachment loss,
periodontal abscess, loss of vestibular depth, root
migration, and microscopic cysts at extruded endodontic
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 130 Issue 2
obturation material (Table 3). In the human studies, the
more serious complications (infection or roots requiring
extraction) occurred in (at least) 18 of 475 submerged
roots. Lam9 reported exfoliation (exposure) in 4 in-
dividuals from residual infection. These exposed roots
were removed, but their number was not reported.
Murray and Adkins38 reported that 1 of 8 roots developed
a sinus tract. Periapical pathology was reported in 4
studies: 1 of 9 roots by Van Wowern and Winther,41 4 of
8 roots by Bowles and Daniel,45 1 of 20 roots by Shankar
et al,51 and 5 of 21 roots by MacEntee et al,44 with a total
complication rate of 2.3%. Stein and Lasnier42 reported a
periodontal abscess in 1 of 3 roots. Nagaoka and
Okuno55 reported progressive periodontal disease in 1
submerged canine root. Though, periodontal defects
have been treated by submerging roots.64,65
DISCUSSION
The null hypothesis was rejected because a detailed
analysis of all the available data on root submergence
techniques supported its use as a ridge preservation
procedure. These data total 733 teeth in both humans
and animals, from single case reports to studies of 122
submerged roots, from 25 days to 8 years of follow-up,
and published in the past 5 decades. However, report-
ing on the technique has dwindled, while placing artifi-
cial bone and biomaterials in extraction sockets has
become more popular.
A decline in root submergence technique reports and,
thus, in the knowledge available suggests a decline in the
teaching and training of the technique, possibly because
of its perceived complications. The data assessed in the
present review report on several complications, including
root exposure, and complication rates from 0% to 100%
have been reported. When comparing these historic data
Du Toit et al
August 2023 193

Table 2. Exposure of roots among both animal and human studies

Human Studies Possible Reasons for Exposure
Other Complications Inappropriate Flap Root Reduction Above Removable Denture
Authors Total Number of Exposures d.t. Exposures Management Crest Pressure
Lam et al, 19729 4 of 10 patients* Not reported No description of Roots sectioned outside Possible
achieving tension-free the mouth, possibly not
flap closure at crest or below crest
Simon et al, 197416 5 of 18 roots Not reported No description of Some roots reimplanted Possible
achieving tension-free above bone crest
flap closure
Von Wowern and Winther, 197622 Not reported None Exposure if only buccal No Possible
flap advancement
Welker et al, 197837 3 of 12 roots None No No Possible
Murray and Adkins, 197938 4 of 8 roots Not reported 3 of 4 exposures d.t. No Possible
absence of any closure
method
Masterson, 197939 10 of 20 roots Not reported No No Possible
Delivanis et al, 198040 2 of 8 roots Pain, discomfort No Not reported Possible
Von Wowern and Winther, 198141 11 of 19 roots Crestal bone loss at No No Possible
exposed roots. 1
periapical cyst
Stein and Lasnier, 198242 1 of 3 roots Periodontal abscess No description of No Possible
achieving tension-free
flap closure
Veldhuis et al, 198143 24 of 32 roots 2 roots developed No description of No d
necrotic pulps achieving tension-free
flap closure
MacEntee et al, 198244 9 of 21 roots 3 roots developed apical No No Possible
pathology
Bowles and Daniel, 198345 4 of 8 roots Exposed roots No description of No Possible
developed apical achieving tension-free
pathology flap closure
Adamich and Gongloff, 198546 1 of 7 roots Pain, discomfort No No Possible
Hylton, 198647 4 of 4 roots Granulation lesion No description of Not reported d
reported at 1 root achieving [initial]
tension-free flap closure
Gongloff, 198648 32 of 122 roots Not reported No Reduced slightly above Possible
crest and rounded or
convex
Fareed et al, 198949 2 of 15 roots Not reported No No Possible
Comut et al, 201350 2 of 2 roots Not reported Initially no intervention Reduced 1 mm above No
to close. Later closed by bone crest
CTG
Shankar et al, 201351 2 of 20 roots Apical pathology No description of No Possible
achieving tension-free
flap closure

Animal Studies Possible Reasons for Exposure

Inappropriate Flap
Total Number of Other Complications Management (Absence Root Reduction Above
Authors Exposures d.t. Exposures of Releasing Incisions) Crest Other Causes
Whitaker and Shankle, 21 of 36 roots Pulpal inflammation or No Sharp root fragments Hard diet, trauma to
197417 necrosis d.t. mallet and chisel surgical wounds
decoronation
Johnson et al, 197414 1 of 24 roots Inflammatory cell No No Not reported
infiltrate
Levin et al, 197415 1 of 16 roots Not reported No description of Possibly. Sharp coronal Not reported
achieving tension-free aspect
flap closure
Reames et al, 197519 2 of 24 roots Not reported No No Not reported
Plata and Kelln, 197621 2 of 12 roots Inflammation, sinus tract No description of Exposure at roots not Not reported
at 1 root, bone achieving tension-free reduced below bone
resorption flap closure crest
Lambert et al, 198335 1 of 44 roots Not reported No. Sites grafted with No Possible hard diet. Possible lack
soft tissue of
keratinized mucosa.
Lambert and Marquad, 6 of 48 roots Inflammatory cell No. Sites grafted with No Possible hard diet
198436 infiltrate soft tissue

d.t., due to; mm, millimeter. *Patient level not comparable to tooth/root level. Authors did not report number of roots exposed. 4 patients=4 roots minimum.

Du Toit et al THE JOURNAL OF PROSTHETIC DENTISTRY

194 Volume 130 Issue 2

Table 3. Human studies reporting on root submergence technique (RST) for ridge preservation
Adverse Outcomes Positive Outcomes
S. No. Authors Cohort Decoronation Method Closure Method Outcome Types Reported Reported
1 Goska and  Case report  Sectioned with  No closure  Clinical  None reported  (Subjective)
Vandrak,  3 roots diamond disk  Radiographic “Improved ridge
197213  Removable  Reduced to bone contour”
denture crest
treatment  Endodontic
 2 y follow-up treatment
2 Lam, 19729  Prospective  Tooth extraction,  Method not  Clinical  “Exfoliation  Radiographic ridge
study, 10 endodontic reported  Radiographic [exposure] in 4 preservation
patients (in treatment,  “Sutures were  Histologic subjects due to  Radiographic
root re- reimplantation placed” residual infection” coronal bridging
implantation  Sectioned with an  No description  Exposed roots of hard tissue over
arm)a irrigated diamond of achieving removed, number roots
 Total number disc outside mouth tension-free not reported
not reported  Endodontic flap closure  Radiographic and
 Removable treatment, sealing histologic root
denture with amalgam resorption
treatment material
 2 y follow-up
3 Simon et al,  Prospective  Tooth extraction,  Method not  Clinical  2 roots exposed  (Subjective) Ridge
197416 trial, 5 endodontic reported  Radiographic when reimplanted preservation at
patients treatment,  “Securely above bone crest submerged root
 Split mouth reimplantation closed”  3 additional late sites compared to
design  Coronectomy and  No description exposures contralateral
 18 apicoectomy, of achieving  Crestal bone
mandibular method not tension-free resorption
roots reported flap closure  Root resorption
submerged,  Reimplanted 1 mm
contralateral below bone crest
roots
extracted
 Removable
denture
treatment
 18 mo follow-
up
4 Guyer,  Case report  Sectioned with  Reported full  Clinical  None reported  (Subjective) Ridge
197518  2 mandibular high-speed, irri- closure by  Radiographic preservation
canine roots gated bur sutures
 Removable  Reduced to bone  No description
denture crest of achieving
treatment  Vital roots, no tension-free
 2 y follow-up endodontic flap closure
treatment
5 Simon et al,  Case series, 2  Tooth extraction,  Method not  Clinical  Case 1, 3 roots  No symptoms in
197520 patients endodontic reported  Radiographic exposed either patients
 3 roots each, treatment,  “Securely  Histologic  Histologic and  Case 2, 3 roots
6 roots total reimplantation closed” radiographic remained
 Removable  Coronectomy and  No description resorption submerged
denture apicoectomy, of achieving  Histologic after 2 y
treatment method not tension-free inflammation
 Up to 30 mo reported flap closure
follow-up  Reimplanted 1 mm
below bone crest
6 von  Case series, 17  Decoronation  Advanced  Clinical  Exposure if only  Complete
Wowern patients method not flaps buccal advanced coverage if both
and  27 roots total reported  No description flap lingual and buccal
Winther,  Removable  Reduced to bone of achieving flaps advanced
197622 denture crest tension-free  (Subjective) Ridge
treatment  Endodontic flap closure preservation
 2 mo follow- treatment
up
7 Garver  Prospective  Sectioned with  Advanced  Clinical  None reported  Complete
et al, study, 2 high-speed, irri- flaps, split-  Radiographic coverage if flaps
197852 patients gated bur thickness, ver- everted by sutures
 6 mandibular  Reduced to bone tical release  Patient-reported
roots each, 12 crest incisions jaw
roots total  Vital roots, no  Flaps everted proprioception
 Removable endodontic by sutures
denture treatment
treatment
 2 y follow-up
(continued on next page)

THE JOURNAL OF PROSTHETIC DENTISTRY Du Toit et al

August 2023 195

Table 3. (Continued) Human studies reporting on root submergence technique (RST) for ridge preservation
Adverse Outcomes Positive Outcomes
S. No. Authors Cohort Decoronation Method Closure Method Outcome Types Reported Reported
8 Welker  Case series, 6  Sectioned with  Various,  Clinical  3 of 12 roots  (Subjective) Ridge
et al, patients high-speed, irri- advanced  Radiographic exposed preservation
197837  12 roots total gated bur flaps, pedicle  “All patients [had]
 Removable  Reduced to bone flaps favorable denture
denture crest or “slightly  No description experience”
treatment below” of achieving
 1 to 4 y  Vital roots, no tension-free
follow-up endodontic flap closure
treatment
9 Murray and  Case series, 4  Sectioned with  Various, buccal  Clinical  1 root with a sinus  No root resorption
Adkins, patients high-speed irri- pedicle flap  Radiographic tract  Histologic vitality
197938  8 canine roots gated bur closure  Histologic  4 roots exposed confirmed at
total  Reduced to bone compared to  Bone loss at some some roots
 Removable crest, facial aspect no flap or roots  Histologic and
denture 1-3 mm below closure radiographic bone
treatment crest growth over some
 2 roots  Vital roots, no roots
removed for endodontic
histology treatment
 2 y follow-up
10 Masterson,  Case series, 10  Sectioned with  Advanced  Clinical  2 roots exposed,  10 roots remained
197939 patients “appropriate bur” flaps with  Radiographic resubmerged submerged
 20  Reduced 2 mm periosteal  8 roots exposed
mandibular below crest release and removed
roots total  Vital roots, no incisions  Variable alveolar
 Removable endodontic bone resorption
denture treatment reported
treatment
 Up to 18 mo
follow-up
11 Garver and  Prospective  Sectioned with  Unclear/  Clinical  Crestal bone loss at  Roots remained
Fenster, study, 10 high-speed, irri- various:  Radiographic roots without submerged in 9/10
198053,b patients gated rotary bur Advanced “presurgical patients
 45 roots total  Reduced to bone flaps, split- debridement”
 Removable crest thickness, ver-  1 patient with
denture  Vital roots, no tical release discomfort,
treatment endodontic incisions requested roots
 3 y follow-up treatment  Other cases: removal
“deep
periosteal
dissection” and
advancement
only
12 Delivanis  Case report  Decoronation  Advanced  Clinical  Exposure of  Remaining roots
et al,  8 roots method not flaps, release  Radiographic maxillary canine submerged
198040  Removable reported incisions roots at 24 mo
denture  Roots extracted
treatment
 24 mo follow-
up
13 Veldhuis  Case series, 16  Sectioned with  “Primary  Clinical  24 of 32 roots  All roots initially
et al, patients high-speed, irri- closure of the  Radiographic exposed submerged
198143  Lower canine gated rotary bur mobilized  Histologic  9 roots later  No pain/
roots only, 32  Reduced 2 mm mucosa” extracted, reasons discomfort of any
roots total below crest  No description not stated patients
 Removable  Vital roots, no of achieving  2 extracted roots  Histologic vitality
denture endodontic tension-free with necrotic pulps confirmed at 5 of 7
treatment treatment flap closure roots
 Up to 5 y
follow-up
14 Von  Retrospective  Decoronation  Advanced  Clinical  11 of 19 roots  8 of 19 roots
Wowern study, 14 method not flaps  Radiographic exposed, without remained
and patients reported  No description inflammation submerged
Winther,  19 roots total  Reduced to bone of achieving  Crestal bone loss at  Radiographic bone
198141  Removable crest tension-free exposed roots preservation in 9
denture  Endodontic flap closure  1 root developed cases
treatment treatment periapical cyst
 Up to 4 y
follow-up
(continued on next page)

Du Toit et al THE JOURNAL OF PROSTHETIC DENTISTRY

196 Volume 130 Issue 2

Table 3. (Continued) Human studies reporting on root submergence technique (RST) for ridge preservation
Adverse Outcomes Positive Outcomes
S. No. Authors Cohort Decoronation Method Closure Method Outcome Types Reported Reported
15 Dugan  Case report  Sectioned with  Advanced  Clinical  “Some bone loss  (Subjective) Ridge
et al,  19 roots mallet and chisel flaps  Radiographic did occur”c preservation
198154  Removable  Reduced to bone  No description
denture crest (with low- of achieving
treatment speed bur) tension-free
 24 mo follow-  Vital roots, no flap closure
up endodontic
treatment
16 Nagaoka  Case report  Decoronation  Flap  Clinical  Progressive  None reported
and Okuno,  1 maxillary method not management  Radiographic periodontal disease
198155 canine root reported not reported  Submerged root
 Removable  Reduced to 2 mm extracted
denture below bone crest
treatment  Endodontic
 8 y follow-up treatment
17 Stein and  Case report  Sectioned with  Mattress  Clinical  Exposure of  2 of 3 roots
Lasnier,  3 maxillary high-speed, irri- sutures canine root, remained
198242 anterior roots gated rotary bur  No description periodontal abscess, submerged
 Removable  Reduced to bone of achieving extraction at 2 mo
denture crest tension-free
treatment  Vital roots, no flap closure
 6 mo follow- endodontic
up treatment
18 MacEntee  Case series, 8  Sectioned with  Advanced  Clinical  9 roots exposed  12 of 21 roots
et al, patients low-speed, irri- flaps, mattress  Radiographic  3 exposed roots maintained
198244  21 roots total gated rotary bur sutures converted to submergence
 Removable  Reduced to bone  No description overdenture  [Subjective] Ridge
denture crest of achieving abutments preservation
treatment  17 Vital roots, 4 tension-free  3 roots extracted  “Neither bone nor
 Up to 34 mo endodontic treated flap closure due to apical root changes with
follow-up roots pathology overlying mucosa
 Fistula at 2 roots, remained intact”
1 extracted
 2 exposed roots
untreated
19 Bowles and  Case series, 2  Sectioned with  Flap raised  Clinical  Case 1, 3 of 4  4 of 8 roots
Daniel, patients high-speed, irri- and  Radiographic roots exposed remained
198345  8 roots total gated rotary bur approximated  Histologic  Case 2, 1 of 4 submerged, no
 Removable  Case 1, crowns  No description roots exposed pathology at recall
denture fractured with of achieving  Apical pathology at
treatment forceps, then tension-free all exposed roots
 3.5 y and 2 y “beveled at flap closure
follow up approximately 0.5
e 1 mm below
crest”.
 Case 2, crowns
removed with bur,
crestal level not
reported
 Vital roots, no
endodontic
treatment
20 Simon and  Case report  Sectioned with  Method of  Clinical  None observed at  (Subjective) Ridge
Luebke,  1 maxillary high-speed, irri- closure not  Radiographic follow-up preservation
198356 central incisor gated rotary bur reported  Radiographic
 Fixed partial  “Submerged well coronal bridging
denture below the alveolar  Absence of
treatment crest”d radiographic
 1 y follow-up  Endodontic pathology
treatment
21 Garver and  Case report  Sectioned with  Flap raised  Clinical  None reported  “Favorable for
Muir,  6 maxillary high-speed, irri- and  Radiographic alveolar ridge
198357 roots gated rotary bur approximated preservation”
 Removable  Reduced to bone  “Deep
denture crest periosteal
treatment  Vital roots, no dissection”
 Follow-up endodontic
period not treatment
reported
(continued on next page)

THE JOURNAL OF PROSTHETIC DENTISTRY Du Toit et al

August 2023 197

Table 3. (Continued) Human studies reporting on root submergence technique (RST) for ridge preservation
Adverse Outcomes Positive Outcomes
S. No. Authors Cohort Decoronation Method Closure Method Outcome Types Reported Reported
22 Adamich  Case report  Sectioned with  Advanced  Clinical  1 of 7 roots  (Subjective) Ridge
and  7 roots total high-speed, irri- flaps with exposed preservation
Gongloff,  Removable gated rotary bur periosteal  Exposed root
198546 denture  Reduced to bone release extracted
treatment crest incisions,
 28 mo follow-  Vital roots, no mattress
up endodontic sutures
treatment
23 Gongloff,  Retrospective  Decoronation  Advanced  Clinical  32 of 122 roots  90 of 122 vital
198648 study, 49 method not flaps with  Radiographic exposed roots remained
patients reported periosteal  Majority of submerged 6 mo
 122 roots  Reduced above release exposures during to 5 y
total bone crest, coronal incisions, immediate
 Removable root rounded and mattress postoperative
denture convex sutures period
treatment  Vital roots, no  Some exposed
 Up to 5 y endodontic roots removed
follow-up treatment  Vestibule depth
loss due to
advanced flaps
24 Hylton,  Case series, 2  Decoronation  Case 1, rotated  Clinical  4 of 4 roots  4 of 4 roots
198647 patients method not pedicle flaps initially exposed remained
 2 maxillary, 2 reported  Case 1,  Reactive granulation submerged at 1 y
mandibular  Reduced 1 mm undermined lesion at 1 exposed when further
canine roots, below bone crest flaps to reduce root reduced below
4 roots total  Vital roots, no tension bone crest and
 Removable endodontic flaps managed
denture treatment
treatment
 1 y follow-up
25 Ianzano  Case report  Sectioned with  Advanced  Clinical  None  (Subjective) Ridge
et al,  1 central high-speed, irri- flaps with  Radiographic preservation
198858 incisor root gated bur periosteal
 Fixed partial  Reduced to release
denture alveolar crest incisions
treatment  Endodontic
 6 mo follow- treatment
up
26 Fareed  Case series, 6  Decoronation  Advanced  Clinical  2 roots exposed  13 roots remained
et al, patients method not flaps with  Radiographic submerged
198949  15 roots total reported periosteal
 Removable  Reduced to release
denture alveolar crest incisions,
treatment  Vital roots, no mattress
 Up to 1 y endodontic sutures
follow-up treatment
27 Bencie,  Case report  Decoronation  Flaps  Clinical  None reported  Full mucosal
199159  1 maxillary method not approximated  Radiographic coverage
incisor reported  No description  (Subjective) Ridge
 Fixed partial  Reduced 2 to of achieving preservation
denture 3 mm below bone tension-free  Radiographic bone
treatment crest flap closure growth over root
 6 mo follow-  Endodontic
up treatment
28 Wallace  Case report  Decoronation  Flaps  Clinical  None reported  Full mucosal
et al,  1 maxillary method not approximated  Radiographic coverage
199460 canine reported  No description  Resolution of
 Removable  Reduced to 2 mm of achieving infection
denture below bone crest tension-free  (Subjective) Ridge
treatment  Endodontic flap closure preservation
 6 mo follow- treatment
up
30 Harper,  Case report  Sectioned with  Advanced  Clinical  None observed at  Full mucosal
200227  1 root high-speed irri- flaps with  Radiographic annual reviews coverage
 Fixed partial gated bur periosteal  (Subjective) Ridge
denture  Reduced to release preservation,
treatment alveolar crest incisions compared to
 6 y follow-up  Endodontic resorption at
treatment adjacent
extraction site
(continued on next page)

Du Toit et al THE JOURNAL OF PROSTHETIC DENTISTRY

 198 Volume 130 Issue 2

Table 3. (Continued) Human studies reporting on root submergence technique (RST) for ridge preservation
Adverse Outcomes Positive Outcomes
S. No. Authors Cohort Decoronation Method Closure Method Outcome Types Reported Reported
31 Salama  Case series, 3  Decoronation  “Soft tissue  Clinical  None observed at  Full mucosal
et al, patients method not grafting over  Radiographic follow-up coverage
200726  5 roots total reported the top”  (Subjective) Ridge
 Implant-  Reduced to bone preservation
supported crest  Enhanced
fixed partial  Both vital and prosthetic-soft-
denture endodontic- tissue esthetics
treatment treated roots
 Up to 2 y
follow-up
32 Hiremath  Case report  Decoronation  Flaps  Clinical  None reported  Full mucosal
et al,  10 roots method not approximated  Radiographic coverage
201061  Removable reported  No description  (Subjective) Ridge
denture  Reduced 2 mm of achieving preservation
treatment below crest tension-free
 18 mo follow-  2 vital roots, 8 flap closure
up endodontic treated
roots
33 Sharma  Control study,  Sectioned with  Advanced  Clinical  None reported  Vertical ridge
et al, 10 patients high-speed, irri- flaps with  Radiographice (bone)
201230  11 roots total, gated rotary bur periosteal preservation
submerged  Ridge contoured release  1.2 mm less bone
root sites with bone file incisions, loss at submerged
compared to  Reduced 2 to 4 mattress roots (RST sites 2.1
extraction mm below bone sutures ±0.7 mm vs 3.3
sites crest ±0.8 mm at
 Removable  Vital roots, no extraction sites)
denture endodontic
treatment treatment
 Up to 9 mo
follow-up
34 Wong et al,  Case report  Decoronation  Sites not  Clinical  None reported  Mucosa healed
201262  2 maxillary method not closed, no  Radiographic over submerged
incisor roots reported flaps roots
 Implant-  Reduced to bone advanced,  (Subjective) Ridge
supported crest adjacent preservation
fixed partial  Endodontic implants
denture treatment placed
treatment
 3 mo follow-
up
35 Comut  Case report  Decoronation  Sites initially  Clinical  Incomplete  (Subjective) Ridge
et al,  2 maxillary method not not closed  Radiographic submergence at 8 preservation
201350 incisor roots reported adjacent weeks, additional
 Implant-  Reduced 1 mm implants reduction to bone
supported above bone crest placed, no crest, CTG graft to
fixed partial  Endodontic flaps advanced cover
denture treatment
treatment
 1 y follow-up
36 Shankar  Case series, 2  Case 1 (vital roots),  Flaps  Clinical  2 roots exposed,  8 of 10 vital roots
et al, patients sectioned to 2 mm advanced and  Radiographic apical pathology, remained
201351  10 roots each, below bone crest approximated and extracted in submerged
20 roots total by mallet and  No description case 1  All nonvital roots
 Removable chisel of achieving remained
denture  Case 2 (nonvital tension-free submerged
treatment roots), Sectioned flap closure
 1 y follow-up with high-speed
irrigated rotary bur
to 2 mm below
bone crest
37 Choi et al,  Case series, 3  Decoronation  Sites not  Clinical  “Minimal  Mucosa healed
201563 patients method not closed, no  Radiographic interproximal bone over submerged
 3 maxillary reported surgical loss” at 1 root roots
lateral incisor  Reduced to bone procedures  (Subjective) Ridge
roots total crest preservation
 Fixed partial  Endodontic
denture treatment
treatment
 Up to 2 y
follow-up

mm, millimeter. aLam 1972.9 Discrepancy in data reported, no data for number of roots submerged, discrepancy in total number of patients treated. bThe same authors, Garver et al, published
preliminary results the year before on the same 10 patients, and thus, the preliminary report in 1979 has been excluded here to avoid repetition. cDugan et al, 1981.54 Not evident on
radiographs. dSimon and Luebke, 1983.56 Appeared reduced 2-3 mm below crest on radiographs. eSharma et al, 201230 Bone loss was assessed on panoramic radiographs. Excusable possibly
for the historic studies, however, not an acceptable objective measure of ridge preservation in a contemporary study.

THE JOURNAL OF PROSTHETIC DENTISTRY Du Toit et al

August 2023
with the most contemporary of surgical techniques to
achieve guided bone regeneration, note that augmenta-
tion is also not without complication. In a single study,
the healing complication rate after guided bone regen-
eration using a titanium mesh was 21.1%.66 In a sys-
tematic review of guided bone regeneration, complication
rates ranged between 0% and 45% (mean 16.8%).67 Most
of the root submergence technique studies reviewed here
(38 of 47) were carried out before 1994. Of the studies
published after 1994, only 4 roots became exposed. One
root was extracted because of apical pathology, 1 was
resubmerged with a soft-tissue graft, and 1 site had
“minimal interproximal bone loss” (Table 3).
Thus, the earlier techniques may have contributed to
the high complication rate. In a 1975 study, Simon
et al20 reported mixed acute and chronic inflammatory
infiltrate in the mucosa overlying 6 of 6 roots at about 2
years postoperatively, at both successfully submerged
and exposed roots. Their results were probably the
result of their technique. These are the only authors in
this review that first extracted patients’ roots, decoro-
nated them outside the mouth, and reimplanted the
roots.16,20 Gound et al34 showed a similar technique of
extraction and reimplantation in an animal study.34 The
unnecessary trauma to these roots and extraction sites
probably exaggerated the inflammation. As stated,
trauma as a reason to submerge roots was omitted from
this review, and thus, the results of Simon et al16,20
could also be disregarded as an inappropriate method
of intentionally submerging roots for ridge
preservation.
Special mention should be made of root exposure
complication. This accounted for a combined complica-
tion rate of 21% (13.2% in animals, 25% in humans). In
humans, exposure was frequently associated with pa-
tients receiving removable denture treatment, probably
because of the pressure from the denture itself, the
denture flange on the periphery of the healing flap, or
contact with the intaglio surface on the mucosa overlying
the submerged root or roots.48 In general, complications
including exposure appear to be more common among
earlier studies that may have used outdated techniques.
In some studies, crowns were removed with a mallet and
chisel, leading to microfractures of the root with sharp
dentin spicules, as identified histologically.17,51 These
probably also contributed to the mucosal dehiscence and
root exposures (Fig. 4). In several studies, the roots were
decoronated occlusal to the bone crest.9,15,21,48,50 Sub-
sequent crestal bone loss positions these roots more
occlusal to the ridge and made the mucosa susceptible to
dehiscence (Fig. 5). An important finding of this review
was that reduction to bone crest, or even below bone
crest, might better ensure coronal bridging of bone and
cementum over the submerged root (Fig. 3). This may
Du Toit et al
199
Figure 4. Histological section, monkey. Submerged root decoronated by
mallet, chisel. Yellow arrows indicate microfractures. Note sharp,
protruding dentin spicules that may contribute to exposure (blue
arrows). Image courtesy of Whitaker and Shankle, 1974.17
ensure longevity of treatment by preventing
exposure.14,15,17,19,21,34-36,38,56,59 Also, the best esthetic
outcomes may be obtained by a soft-tissue graft over the
submerged root,26 also preventing the risk of exposure in
patients with removable dentures and with less chance of
flap dehiscence. Denture flanges may impinge on
approximated flaps because of loss of vestibular depth.
Moreover, when the flaps are approximated without
tension-relieving flap management, the denture may
cause wound dehiscence. This was apparent in several
studies that did not make use of any releasing incisions at
removable denture treatment.9,15,16,21-22,42,43,45,47
CONCLUSIONS
Based on the findings of this systematic review, the
following conclusions were drawn:
1. Root submergence has become a less popular
technique than the use of commercially available
biomaterials, evidenced by the volume of literature
on each.
2. The wealth of literature on the root submergence
technique provides valuable clinical, radiographic,
and histological data of mostly positive healing
outcomes.
3. When aiming to preserve the alveolar ridge, espe-
cially at pontic sites and adjacent to implants, the
root submergence technique is an established,
evidence-based treatment option.
4. The data in this review indicate reasons why exposure
is the most common complication, namely incorrect
decoronation level, inappropriate soft-tissue man-
agement, and removable denture treatment.
THE JOURNAL OF PROSTHETIC DENTISTRY
200
Figure 5. A, Immediate postoperative radiograph. Roots extracted, decoronated by diamond disk outside mouth, then reimplanted. B, At six months
postoperatively. C, At eight months postoperatively. Note root with crestal bone resorption, positioning of roots above crest, contributing to mucosal
exposure. Images courtesy of Simon et al, 1974.16
5. The studies reviewed indicate methods that should
be avoided and others that likely would improve
treatment outcomes when selecting this partial
extraction therapy.
REFERENCES
1. Lammie GA. The reduction of the edentulous ridges. J Prosthet Dent 1960;10:
605-11.
2. Sobolik CF. Alveolar bone resorption. J Prosthet Dent 1960;10:612-9.
3. Ortman HR. Factors of bone resorption of the residual ridge. J Prosthet Dent
1962;12:429-40.
4. Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extrac-
tion. An experimental study in the dog. J Clin Periodontol 2005;32:212-8.
5. Scala A, Lang NP, Schweikert MT, de Oliveira JA, Rangel-Garcia I Jr,
Botticelli D. Sequential healing of open extraction sockets: an experimental
study in monkeys. Clin Oral Implants Res 2014;25:288-95.
6. Gluckman H, Pontes CC, Du Toit J. Radial plane tooth position and bone
wall dimensions in the anterior maxilla: a CBCT classification for immediate
implant placement. J Prosthet Dent 2017;120:50-6.
7. Avila-Ortiz G, Chambrone L, Vignoletti F. Effect of alveolar ridge preserva-
tion interventions following tooth extraction: a systematic review and meta-
analysis. J Clin Periodontol 2019;46(Suppl 21):195-223.
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 130 Issue 2
8. Jung RE, Ioannidis A, Hämmerle CHF, Thoma DS. Alveolar ridge preserva-
tion in the esthetic zone. Periodontol 2000 2018;77:165-75.
9. Lam RV. Effect of root implants on resorption of residual ridges. J Prosthet
Dent 1972;27:311-23.
10. Stanley HR, Hench L, Going R, Bennett C, Chellemi SJ, King C, et al. The
implantation of natural tooth form bioglasses in baboons. A preliminary
report. Oral Surg Oral Med Oral Pathol 1976;42:339-56.
11. Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M. Surgical
protocols for ridge preservation after tooth extraction: a systematic review.
Clin Oral Impl Res 2012;23(Suppl 5):22-38.
12. Poe GS, Johnson DL, Hillenbrand DG. Vital root retention in dogs. Naval
Dental School Technical Report. National Naval Medical Center Bethesda
Maryland; 1971. (NDS-TR-019).
13. Goska FA, Vandrak RF. Roots submerged to preserve alveolar bone: a case
report. Mil Med 1972;137:446-7.
14. Johnson DL, Kelly JF, Flinton RJ, Cornell MT. Histologic evaluation of vital
root retention. J Oral Surg 1974;32:829-33.
15. Levin MP, Getter L, Cutright DE, Bhaskar SN. Intentional submucosal
submergence of nonvital roots. J Oral Surg 1974;32:834-9.
16. Simon JH, Kimura JT. Maintenance of alveolar bone by the intentional
replantation of roots. Oral Surg Oral Med Oral Pathol 1974;37:
936-45.
17. Whitaker DD, Shankle RJ. A study of the histologic reaction of submerged
root segments. Oral Surg Oral Med Oral Pathol 1974;37:919-35.
18. Guyer SE. Selectively retained vital roots for partial support of overdentures:
a patient report. J Prosthet Dent 1975;33:258-63.
Du Toit et al
August 2023
19. Reames RL, Nickel JS, Patterson SS, Boone M, el-Kafrawy AH. Clinical,
radiographic, and histological study of endodontically treated retained roots
to preserve alveolar bone. J Endod 1975;1:367-73.
20. Simon JH, Jensen JL, Kimura JT. Histologic observations of endodontically
treated replanted roots. J Endod 1975;1:178-80.
21. Plata RL, Kelln EE, Linda L. Intentional retention of vital submerged roots in
dogs. Oral Surg Oral Med Oral Pathol 1976;42:100-8.
22. von Wowern N, Winther S. Extraction of teeth with root preservation. Int J
Oral Surg 1976;5:192-6.
23. Brewer AA, Morrow RM. Overdentures. 2nd ed. St. Louis: Mosby; 1981. p.
13.
24. Gluckman H, Salama M, Du Toit J. Partial extraction therapies (PET) part 1:
Maintaining alveolar ridge contour at pontic and immediate implant sites. Int
J Periodontics Restorative Dent 2016;36:681-7.
25. Gluckman H, Salama M, Du Toit J. Partial extraction therapies (PET) part 2:
Procedures and technical aspects. Int J Periodontics Restorative Dent 2017;37:
377-85.
26. Salama M, Ishikawa T, Salama H, Funato A, Garber D. Advantages of the
root submergence technique for pontic site development in esthetic implant
therapy. Int J Periodontics Restorative Dent 2007;27:521-7.
27. Harper KA. Submerging an endodontically treated root to preserve the
alveolar ridge under a bridge: a case report. Dent Update 2002;29:200-3.
28. Needleman IG. A guide to systematic reviews. J Clin Periodontol
2002;29(Suppl 3):6-9. discussion 37-8.
29. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for
systematic reviews and meta-analyses: The PRISMA statement. BMJ
2009;339:b2535.
30. Sharma A, Oberoi SS, Saxena S. Submergence of vital roots for the preser-
vation of residual ridge: a clinical study. Oral Health Prev Dent 2012;10:
259-65.
31. Cook RT, Hutchens LH, Burkes EJ. Periodontal osseous defects associated
with vitally submerged roots. J Periodontol 1977;48:249-60.
32. Evian CI, Rosenberg ES, Rossman LE, Lerner SA. The effect of submerging
roots with periodontal defects. Compend Contin Educ Dent 1983;4:37-43.
33. O’Neal RB, Gound T, Levin MP, del Rio CE. Submergence of roots for
alveolar bone preservation. I. Endodontically treated roots. Oral Surg Oral
Med Oral Pathol 1978;45:803-10.
34. Gound T, O’Neal RB, del Rio CE, Levin MP. Submergence of roots for
alveolar bone preservation. II. Reimplanted endodontically treated roots. Oral
Surg Oral Med Oral Pathol 1978;46:114-22.
35. Lambert PM, Skerl RF, Campana HA. Free autogenous graft coverage of vital
retained roots. J Prosthet Dent 1983;50:611-7.
36. Lambert PM, Marquard JV. Autogenous dermal graft coverage of submerged
roots in the dog. J Oral Maxillofac Surg 1984;42:595-9.
37. Welker WA, Jividen GJ, Kramer DC. Preventive prosthodontics: Mucosal
coverage of roots. J Prosthet Dent 1978;40:619-21.
38. Murray CG, Adkins KF. The elective retention of vital roots for alveolar bone
preservation: a pilot study. J Oral Surg 1979;37:650-6.
39. Masterson MP. Retention of vital submerged roots under complete dentures:
Report of 10 patients. J Prosthet Dent 1979;41:12-5.
40. Delivanis P, Day O, Esposito C, Bickley R. Clinical considerations for root-
submergence procedures. J Prosthet Dent 1980;43:487-90.
41. von Wowern N, Winther S. Submergence of roots for alveolar ridge pres-
ervation: a failure 4-year follow-up study. Int J Oral Surg 1981;10:247-50.
42. Stein D, Lasnier RP. Vital root retention. J Conn State Dent Assoc 1982;56:
113-4.
43. Veldhuis A, Schade G, Denissen H, Sillevis SP. Submerged tooth roots in
preventive prosthetic dentistry. Clin Prev Dent 1981:13-5.
44. MacEntee MI, Goldstein BM, Price C. Submucosal root retention. A two-year
clinical observation. J Prosthet Dent 1982;47:483-7.
45. Bowles WH, Daniel RE. Reevaluation of submerged vital roots. J Am Dent
Assoc 1983;107:429-32.
46. Adamich TS, Gongloff RK. Vital root submersion: an adjunct for conventional
complete denture therapy for the sick and the elderly patient. Gerodontics
1985;1:108-10.
47. Hylton RP Jr. Improving host acceptance of submucosal submersion of tooth
roots by observing basic surgical principles. Gen Dent 1986;34:390-5.
48. Gongloff RK. Vital root retention: a 5-year experience. Int J Oral Maxillofac
Surg 1986;15:33-8.
Du Toit et al
201
49. Fareed K, Khayat R, Salins P. Vital root retention: a clinical procedure.
J Prosthet Dent 1989;62:430-4.
50. Comut A, Mehra M, Saito H. Pontic site development with a root submer-
gence technique for a screw-retained prosthesis in the anterior maxilla.
J Prosthet Dent 2013;110:337-43.
51. Shankar YR, Srinivas K, Surapaneni H, Reddy SV. Prosthodontic treatment
using vital and non vital submerged roots-two case reports. J Clin Diagn Res
2013;7:2396-9.
52. Garver DG, Fenster RK, Baker RD, Johnson DL. Vital root retention in
humans: a preliminary report. J Prosthet Dent 1978;40:23-8.
53. Garver DG, Fenster RK. Vital root retention in humans: a final report.
J Prosthet Dent 1980;43:368-73.
54. Dugan DJ, Getz JB, Epker BN. Root banking to preserve alveolar bone: a
review and clinical recommendation. J Am Dent Assoc 1981;103:737-43.
55. Nagaoka E, Okuno Y. A case treated with overdenture utilizing a root-sub-
mergence procedure and its follow-up evaluation. J Osaka Univ Dent Sch
1981;21:233-44.
56. Simon JF, Luebke RG. Ridge preservation through root submergence. Gen
Dent 1983;31:304-6.
57. Garver DG, Muir TE. The retention of vital submucosal roots under imme-
diate dentures: a surgical procedure. J Prosthet Dent 1983;50:753-6.
58. Ianzano JA, Baer PN, Iacono VJ. Ridge maintenance by root submergence.
Periodontal Case Rep 1988;10:11-3.
59. Bencie N. Root submersion: a technique for function and aesthetics. Pract
Periodontics Aesthet Dent 1991;3:14-7.
60. Wallace JA, Carman JE, Jimenez J. Endodontic therapy and root
submersion of an impacted maxillary canine. A case report and review of
the root submergence concept. Oral Surg Oral Med Oral Pathol 1994;77:
519-22.
61. Hiremath HP, Doshi YS, Kulkarni SS, Purbay SK. Endodontic treatment in
submerged roots: a case report. J Dent Res Dent Clin Dent Prospects 2010;4:
64-8.
62. Wong KM, Chneh CM, Ang CW. Modified root submergence technique
for multiple implant-supported maxillary anterior restorations in a patient
with thin gingival biotype: a clinical report. J Prosthet Dent 2012;107:
349-52.
63. Choi S, Yeo IS, Kim SH, Lee JB, Cheong CW, Han JS. A root submergence
technique for pontic site development in fixed dental prostheses in the
maxillary anterior esthetic zone. J Periodontal Implant Sci 2015;45:152-5.
64. Björn H, Hollender L, Lindhe J. Tissue regeneration in patients with peri-
odontal disease. Odontol Revy 1965;16:317-26.
65. Bowers GM, Chadroff B, Carnevale R, Mellonig J, Corio R, Emerson J, et al.
Histologic evaluation of new attachment apparatus formation in humans:
Part I. J Periodontol 1989;60:664-74.
66. Cucchi A, Vignudelli E, Napolitano A, Marchetti C, Corinaldesi G. Evaluation
of complication rates and vertical bone gain after guided bone regeneration
with non-resorbable membranes versus titanium meshes and resorbable
membranes: a randomized clinical trial. Clin Implant Dent Relat Res 2017;19:
821-32.
67. Lim G, Lin GH, Monje A, Chan HL, Wang HL. Wound healing complica-
tions following guided bone regeneration for ridge augmentation: a sys-
tematic review and meta-analysis. Int J Oral Maxillofac Implants 2018;33:
41-50.
Corresponding author:
Dr Jonathan Du Toit
879 Tennis Rd
Unit 2 The Gables Office Park, Weltevreden Park
Johannesburg
SOUTH AFRICA
Email: docjdt@periodoc.co.za
Acknowledgments
The authors thank Mrs Emelia Minnaar for the many months of assistance in
collecting these historic full texts from libraries around the world.
Copyright © 2021 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2021.08.009
THE JOURNAL OF PROSTHETIC DENTISTRY