What works best to preserve the jaw bone after tooth extraction?

Momen A Atieh, Nabeel HM Alsabeeha, Alan GT Payne, Sara Ali, Clovis M Faggion Jr, Marco Esposito

Why is this question important?

Tooth extraction is a common procedure that can be used for example to:

- remove damaged or diseased teeth;
- remove teeth that are in the wrong place; or
- make room for other teeth.

After a tooth extraction, the part of the jaw bone that used to hold the tooth shrinks because it is no longer needed to support the tooth. If the bone shrinks too much, this can:

- make it difficult or impossible to replace the missing tooth with an artificial one (an implant); and
- weaken the support and health of neighbouring teeth.

To limit bone loss after tooth extraction, dentists or surgeons can carry out a procedure called alveolar ridge preservation (ARP). ARP involves filling the hole left by the missing tooth (using a range of different materials and techniques), and leaving it to heal for several months. The hole can be filled with human, animal, or artificial bone. It can be covered over (to stop gums from growing into the hole) using:

- materials that, after some time, are naturally absorbed by the body; or
- materials that need to be removed with surgery once no longer needed.

To find out if ARP works to preserve jaw bone after tooth extraction, we reviewed the evidence from research studies. We also wanted to know if any materials and ARP techniques are better than others.

How did we identify and evaluate the evidence?

First, we searched the medical literature for studies that compared:

- ARP against no ARP; or
- different ARP materials or techniques.

We then compared the results, and summarised the evidence from all the studies. Finally, we rated our confidence in the evidence, based on factors such as study methods and sizes, and the consistency of findings across studies.

What did we find?

We found 16 studies that followed a total of 426 adults for at least six months. The studies took place in North America, South America, Europe, and Asia. Four studies were supported by pharmaceutical and medical device companies. The other studies either received public funding, no specific funding, or did not report funding source.

ARP compared to no ARP

Eight studies compared ARP against no ARP. In seven studies, animal bone was used to fill the hole left by the missing tooth. In one study, the hole was filled with an artificial bone.

Bone loss: evidence from studies suggests that ARP may prevent bone loss after tooth extraction. However, we are not confident about this finding. This is because studies reported conflicting findings and did not report their methods clearly.

Complications: the evidence about complications (such as discomfort or pain) was mixed. One study reported delayed healing in one person following ARP. In another, some people experienced pain and swelling after ARP. Others reported no complications.

Implications for tooth implants: evidence from studies where ARP used animal bones suggests that ARP may make little or no difference to the need to add more bone to the jaw before implants can be inserted. However, we are not confident about this finding. This is because studies reported conflicting findings and did not report their methods clearly.

It is unclear if ARP affects the success of implants, or the appearance of teeth after implantation. This is because too few robust studies have investigated this.

Comparisons between different materials

Eight studies compared the use of different ARP materials (animal bone against artificial bone). In general, these studies did not provide sufficiently robust evidence to determine which materials work best.

Bone loss: there was some evidence to suggest that there may be little or no difference in bone loss between animal bone and artificial bone. However, we are not confident about this finding. This is because studies reported conflicting findings and did not report their methods clearly.

Complications: the evidence about complications was mixed. Some studies reported redness, pain or swelling, but others did not report that any complications had occurred.

Implications for tooth implants: evidence suggests that the material used may make little or no difference to the need to add more bone to the jaw before implants can be inserted. However, we are not confident about this finding. This is because studies reported conflicting findings and did not report their methods clearly.

It is unclear if different ARP materials and methods have different effects on the success of implants, or the appearance of teeth after implantation. This is because too few robust studies have investigated this.

What does this mean?

We do not know what works best to preserve jaw bone after tooth extraction. It is not clear :

- if ARP is better than no ARP; or
- if some ARP materials and techniques are better than others.

This is because the evidence currently available is not sufficiently robust.

Future studies that report their methods clearly and follow people over long periods will help to strengthen the evidence and draw conclusions.

How-up-to date is this review?

The evidence is current to March 2021.

Atieh MA , Alsabeeha NHM , Payne AGT , Ali S , Faggion CM Jr , Esposito M . Interventions for replacing missing teeth: alveolar ridge preservation techniques for dental implant site development. Cochrane Database of Systematic Reviews 2021, Issue 4. Art. No.: CD010176. DOI: 10.1002/14651858.CD010176.pub3.

Read the full review.