Periodontology 2000, Vol.

66, 2014, 97105

Printed in Singapore. All rights reserved

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

PERIODONTOLOGY 2000

Critical buccal bone dimensions

along implants
JOE MERHEB, MARC QUIRYNEN & WIM TEUGHELS

Over time, dental implants have evolved from being

merely an anchoring device for dental prostheses to
an advanced tooth substitute expected to mimic the
role of a tooth root and to provide levels of functionality, esthetics and phonetics that are comparable
with those of natural teeth. The scientic literature,
when evaluating the outcome of implant therapy, has
switched from the analysis of implant survival, in
other terms equivalent to the implant still being
anchored in the jawbone, to the analysis of implant
success, a more elaborate notion that judges implanttherapy outcome on the grounds of several biological,
biomechanical, functional and esthetic criteria. Several authors have attempted to fragment evaluation
of the esthetic result of rehabilitation with dental
implants into a set of objective criteria. Lately, the
concepts of the pink esthetic score, a soft-tissuerelated set of criteria (30), and the white esthetic
score, a score based on dental-related criteria (8),
have been cited and used in numerous publications
related to esthetic implant dentistry. Based on the
concept of biological width and on empirical observations and experimental ndings, it is suggested that
the integrity of the hard-tissue envelope around
implants is necessary to provide a stable infrastructure for the overlying soft tissue to ensure satisfactory
long-term esthetics and success of implant therapy
(9). The peri-implant bone dimensions constitute the
base for the supra-crestal soft tissues (13). Because
the latter determines the esthetic result and has relatively constant dimensions (36), the bone dimension
is one of the key factors that determines the soft-tissue contour. Special attention has been given to the
buccal bone, especially in the maxilla, because of its
localization in the main esthetic area.
Esthetic success is suggested to be dependent on
achieving an optimal three-dimensional implant
position within the available bone dimensions (14)
and the maintenance of adequate buccal bone over

the buccal implant surface (32). Bone remodeling or

resorption can be a physiological or a pathological
process that occurs as a response to trauma, or to
physical, chemical or microbiological events taking
place in the vicinity of an implant site. Three
bone-remodeling processes determine the bonedimensional changes at implant recipient sites under
normal
physiological
conditions:
remodeling
processes that occur after tooth extraction (33);
remodeling processes that occur as a result of surgical
trauma (31); and bone remodeling processes that
occur as a result of saucerization (1). It is the surgeons duty to be aware of those dynamics and their
extent, as well as their implications on therapy prognosis, in order to offer the most adequate treatment
modalities to the patient.
Particular attention needs to be given to the buccal
bone because of its extensive remodeling ability (4) as
well as its role in supporting the esthetic buccal
mucosa. Implant positioning in relation to the buccooral dimensions of the alveolar ridge is thought to
inuence the degree of bone remodeling following
implant placement (24). As a general principle,
endosseous implants should be installed within the
alveolar envelope at implant placement (42). However, bone remodeling after implant installation may,
in turn, have a negative inuence on the soft-tissue
topography and the esthetic outcome of the implant
therapy (17). Therefore, when performing surgery on
the peri-implant tissues or in the vicinity of an
implant site, the surgeon will have to use techniques
that inict a minimal amount of iatrogenic trauma to
the tissues (the techniques and instrumentation currently available do not yet allow truly completely
atraumatic interventions). Additionally, when faced
with partial or total damage and/or the absence of
buccal bony tissue, the surgeon needs to be able to
make the correct diagnosis and employ suitable
methods in order to repair and correct, or at least

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Merheb et al.

reduce, the extent of the damage inicted on the

tissue.

Anatomical review
The buccal bone plate is a component of the alveolar
process, which is linked to the development and
eruption of the teeth. The alveolar process is very
responsive to changes occurring in the dental structures it supports. Via constant remodeling (a combination of bone-resorption and bone-apposition
processes) it can adapt to physiologic and pathological changes affecting the teeth, such as tooth eruption, natural or forced tooth movement, varying
stress intensity and frequency, development of infection foci and surgical trauma. The buccal bone plate
is a structure comprised of an external (buccal) lining
of cortical bone and an internal (oral) socket wall
made of compact bone, also known as alveolar bone
proper, and is identied as lamina dura on radiographs. In between those plates lies a core body of
cancellous bone. This has been found to be generally
thinner than its palatal/lingual counterpart and
therefore more prone to osseous dehiscences and
fenestrations and subsequent soft-tissue recession
(18). Additionally, it tends to be thicker in the posterior regions than in the anterior regions. Its oral component forms part of the tooth socket and is
composed of bundle bone, which serves as an anchor
point for the periodontal Sharpeys bers. The presence of bundle bone is conditioned by the presence
of an adjacent tooth, and tooth loss or removal leads
inevitably to the loss of bundle bone and subsequently to partial resorption of the buccal bone plate.
The vascularization of the buccal bone plate originates from the superior and inferior alveolar arteries.
The nourishing canals of those arteries run through
the bony structures within the Haversian canals and
the Volkmann canals. Anastomoses are frequent.
Although several nerves run through the jaw bones or
on its surface, the bone itself does not contain neural
terminations.

Dimensional changes following

tooth extraction
The alveolar ridge in general, and the buccal bone
plate in particular, are prone to extensive remodeling.
Major bone remodeling occurs following tooth
extraction (40, 41, 43) and is mainly a consequence of
the disappearance of bundle bone. The bundle bone

98

is considered to be part of the periodontium and its

presence is coupled to the presence of a tooth root.
This tissue thus resorbs upon tooth extraction or
tooth loss (4).
Healing following tooth extraction in the human
was meticulously described by Amler et al. (2). Chen
et al. (20) summarized extraction socket healing,
based on the description by Amler et al., (2) into ve
stages: (i) formation of the blood clot; (ii) formation
of granulation tissue (within 45 days); (iii) replacement of granulation tissue with connective tissue
(after 1416 days); (iv) calcication of the immature
tissues and bone trabeculae ll (by 6 weeks); and
(v) epithelial closure, completion of bone ll and reduction of osteogenic activity (by 16 weeks).
These results were partially conrmed by later
studies, but an important variability in the rate of
healing was also put forward (48). However, Amler
et al. (2) looked solely at intrasocket healing and did
not report on changes affecting the remaining buccal
and lingual alveolar bone plates.
Bone healing following extraction was followed
more closely by Cardaropoli et al. (16) in the mongrel
dog model, and histological cuts were made at days 1,
3, 7, 14, 30, 60, 90, 120 and 180 postextraction (Fig.1).
 Day 1: the alveole is lled by a coagulum covered
with a layer of inammatory cells.
 Day 3: the marginal part of the coagulum is
replaced with vascularized granulation tissue.
 Day 7: zones of coagulative necrosis are present.
Osteoclasts appear in the marrow spaces and in
the Volkmann canals.
 Day 14: an outer layer of richly vascularized connective tissue appears. The periodontal ligament
disappears.
 Day 30: a well-organized brous connective tissue
lined by a keratinized epithelium is present. The
socket is now lled almost entirely with newly
formed bone.
 Day 60: a woven bone bridge, separating the
socket from the marginal mucosa, appears.
 Day 90: the woven bone is in the process of being
replaced with lamellar bone.
 Day 120: gradual replacement of the woven bone
bridge with lamellar bone.
 Day 180: well-organized bone marrow holding a
large number of adipocytes and few inammatory
cells is present. The formation of trabeculae of
lamellar bone is starting.
Next to intrasocket healing following tooth extraction, marked bone resorption should be expected
during this process (Fig.2). Early studies have shown
that this resorption is particularly marked in the

Buccal bone along implants

Fig. 1. Mesio-distal sections illustrating the extraction socket after different intervals of healing: (a) 1 day, (b) 3 days,
(c) 7 days, (d) 14 days, (e) 30 days, (f) 60 days, (g) 90 days, (h) 120 days, (i) 180 days. Hematoxylin-eosin staining; original
magnication 316. From Cardaropoli et al. (16).

horizontal dimension (57 mm) but is more limited

in the vertical dimension (24 mm) (33, 37). Later
studies conrmed this extensive remodeling in the
horizontal dimension after tooth extraction and
quantied this resorption to be around 6.1 mm in the
horizontal dimension, or 50% of the ridge width, with
two-thirds of the resorption occurring during the rst
3 months of healing (43). In contrast to the early
studies, Schropp et al. (43) found little or no change
in regard to the changes in the vertical dimensions.
On average there was a gain of 0.3 mm buccally and a
loss of 0.8 mm orally. This discrepancy might be a
result of the study of Schropp et al. (43) being limited
to single tooth extractions, with the neighboring teeth
usually still being present. The presence of neighboring teeth is known to hamper extensive resorption in
the vertical dimension (3, 25). Additionally, in a study
on beagle dogs (4), it was shown that the buccal bone
plate is affected much more than the lingual or palatal bone plates, in which the dimensional changes are
discreet. This difference is linked to two factors: rst,
the thickness of the buccal plate, which is thinner
than its palatal or lingual counterparts and thus has a
greater tendency to show dimensional changes consequent to bone remodeling; and, second, the importance of bundle bone in the marginal segment of the
buccal cortical plate, compared with a much reduced

Fig. 2. Bone morphology changes following tooth extraction. The initial contour is drawn in red and the bone contour, 6 months after extraction, is drawn in blue.

prevalence in the lingual plate. As the fate of bundle

bone is directly linked to the presence of the dental
element, tooth loss or extraction will systematically

99

Merheb et al.

lead to the resorption of bundle bone during the

remodeling process.
Different strategies of ridge preservation and socket
management have been described in an effort to minimize bone resorption after tooth extraction and to
optimize the availability of bone volume as well as to
reduce the need for additional bone-augmentation
procedures. Nevins et al. (38) reported that lling the
extraction socket with deproteinized bovine bone
mineral and primary closure of the wound leads to an
average reduction of vertical crest height of 2.42 mm,
whereas this reduction in crest height is 5.24 mm
when no lling material was used. It is, however, of
relevance that their study does not report on vertical
changes but rather on the horizontal dimension
because the measurements reported have the following end-points: a constant anatomical structure (e.g.
the nasal fossae oor); and the level where the ridge
is 6 mm wide, a reference level which is expected to
move apically following bone remodeling in the lateral direction. Another socket-management technique, termed the soft-tissue punch technique, was
described by Jung et al. (34). This technique consists
of lling the socket with a xenograft consisting of deproteinized bovine bone mineral integrated in a 10%
collagen matrix (deproteinized bovine bone mineral +
collagen) and closing the wound with a sutured 2- to
3-mm-thick free gingival punch graft harvested from
the palate. Alternative techniques were introduced by
Fickl et al. (27, 29). These involve, in addition to
defect lling with deproteinized bovine bone mineral
+ collagen and primary closure with a soft-tissue
punch, (i) overbuilding of the buccal plate by guided
bone regeneration (resorbable collagen membrane
and deproteinized bovine bone mineral + collagen),
(ii) the insertion of a soft-tissue graft under the buccal
mucosa or (iii) forcing the buccal bone plate into a
more buccal position using a specically designed
instrument. Volumetric changes at 4 months failed to
demonstrate an added value of those techniques in
comparison with the standard soft-tissue punch technique. However, the conclusions of this study were
based on the analysis of soft-tissue contour and volume, and no information or measurements of the
underlying hard-tissue changes were provided. Additionally, ridge preservation seems to have a more
important effect when the initial thickness of the buccal plate is limited. When left to heal without any
additional manipulation, extraction sites with an initial buccal bone plate thickness of 1 mm show a
much higher level of resorption than do sites with an
initial thickness of 3 mm. This difference in initial
buccal bone-plate thickness seemed irrelevant when

100

a ridge-preservation procedure (deproteinized bovine

bone mineral + collagen membrane) was applied (5).

Dimensional changes following

surgical trauma
It has become clear, from different studies, that any
surgical technique by which alveolar bone becomes
exposed during ap elevation will result in increased
osteoclastic activity and bone resorption (12, 23, 39,
45, 46, 50). Mean crestal bone loss after full-thickness
ap elevation has been reported to be between 0.8
and 0.4 mm (26, 28, 46). However, bone exposure is
not the only determining factor for bone remodeling
after a surgical intervention as split-thickness ap elevation also results in increased osteoclastic activity
and bone resorption. This increase in osteoclastic
activity following split-thickness ap elevation is,
however, lower than in cases of full-thickness ap elevation (26, 39). Consequently, the resulting bone
resorption is also lower, but by no means absent (26,
50). It has therefore been concluded that both fulland partial-thickness aps induce bone remodeling.
It might be assumed that the partial-thickness ap
technique has the potential to be superior over fullthickness ap elevation regarding the preservation of
alveolar bone (26).

Dimensional changes caused by

biological width violation
As mentioned before, the success of implant therapy
is partly judged in terms of soft-tissue volume, position and contour around the implant but is not based
on the underlying nonvisible buccal bone plate. The
relevance and importance of the buccal bone plate
arises from its function as the supporting scaffold of
the soft tissues. The concept of biological width has
been applied to implants as well as to teeth. It has
been put forward to explain how a constant distance
has to be maintained between the bottom of the
periodontal or peri-implant pocket/sulcus and the
marginal bone interface to keep pathological microorganisms and their toxic products at bay. Therefore,
it is suggested that whenever this biological width is
violated, marginal bone would resorb in order to recreate an adequate safety distance. Equally, it is
believed that marginal bone resorption caused by an
external insult will lead, in cases of healthy periodontal tissues, to soft-tissue recession in an attempt to

Buccal bone along implants

restore an adequate biological width. Additionally, it

is believed that soft tissues not supported by an adequate underlying bony structure are much more fragile and much more prone to recession in the event of
trauma compared with their supported counterparts.
The biological width around implants has been found
to be slightly greater than that around teeth and
about 33.5 mm in length, comprising a 2-mm junctional epithelium and a connective tissue envelope of
11.5 mm. Additionally, it was observed that the presence of a thin mucosa, implying an insufcient biological width, would invariably lead to spontaneous
bone resorption in order to re-create the minimal epithelial and connective tissue barrier required (9).

Importance of buccal bone

dimensions in relation to implant
positioning
Based on the above-mentioned biological concepts, it
should be clear that bone remodeling and dimensional changes of the buccal bone can be expected
after implant placement (Fig. 3). Cardaropoli et al.
(17) recorded the alterations in the bucco-oral dimensions of 11 single-tooth replacements with implantsupported restorations in the maxillary incisor region.
After the initial extraction sockets had healed for a
period of at least 6 months, a two-stage implant procedure was used with a 6-month submerged healing
period. All implants belonged to the same implant
tenborg, Sweden). After
system (Nobel Biocare, Go
preparing the osteotomy, the implants were placed
with the top of the cover screw positioned even with
the buccal bone crest. This means that the implant

Fig. 3. Bone morphology changes occurring between the

moment of implant placement (red contour) and
12 months after implant placement (green contour).

shoulder was approximately 1.1 mm below the buccal

bony crest. Buccal bone thickness was measured,
using a specially designed device, at the level of the
implant shoulder (1.1 mm below the buccal bone
crest), and 2 and 4 mm more apically. Bone crest levels were measured, using a periodontal probe, from
the implant shoulder. The measurements were performed at implant placement and at abutment connection. The buccal bone thickness at implant
placement was 1.2, 1.3 and 0.9 mm at the three different depth levels. At the two most marginal measurement points, a nonsignicant mean reduction of
0.4 mm in buccal bone thickness was observed at the
second-stage surgery. At that time, a loss of bone
height, averaging 0.7 mm, had taken place at the buccal aspect of the implant.
Implant positioning in relation to the bucco-oral
dimensions of the alveolar ridge is thought to inuence the degree of bone remodeling following
implant placement (24). Such bone remodeling may,
in turn, have a negative inuence on the soft-tissue
topography and on the esthetic outcome of the
implant therapy (17). Taking into account the abovementioned biological concepts, Several clinical guidelines describing the correct implant position in relation to the bucco-oral bone dimension (14, 32).
Regarding the optimal buccal bone dimension
required, it has been suggested that it is crucial to
have a buccal bone plate of at least 1 mm (7) or
2 mm (15, 32). This degree of buccal bone thickness
was advocated to ensure proper soft-tissue support,
avoid resorption of the facial bone wall following restoration and thus minimize the risk for peri-implant
soft-tissue recession. The latter is an important factor
when it comes to esthetics. In order to fulll these criteria, bone-augmentation procedures, orthodontics,
enameloplasty or restorative materials are often recommended (14). Although these criteria might be correctly deduced from the biological concepts of bone
remodeling, the impact at the patient level should not
be underestimated.
Surprisingly, until now, no clinical studies were
available that underlined the necessity of a buccal
bone thickness of 12 mm. Because supracrestal soft
tissues around implants seem to have relatively constant dimensions, which corresponds to the biological
width (36), one could eventually hypothesize that a
vertical buccal bone resorption will result in a marginal soft-tissue recession. In turn, this will have a
negative inuence on the esthetic outcome. Several
studies have addressed the question of whether residual horizontal buccal bone thickness after implant
installation inuences vertical buccal bone resorp-

101

Merheb et al.

tion. Most of the claims in regard to a minimal buccal

bone thickness refer to the large-scale, prospective
and multicenter study of the Dental Implant Clinical
Research Group. In this study, Spray et al. (44) measured the thickness and height of the buccal bone at
the time of implant placement and compared these
values with the buccal bone height at the time of
abutment connection. Data were obtained from 2667
implants with different surfaces and designs and from
original implants as well as replacement implants.
There was no discrimination between intra-oral
regions (anterior, posterior, maxilla and mandible).
Following preparation of the osteotomy site, the
thickness of the buccal bone wall was measured to
the nearest 0.5 mm, approximately 0.5 mm below the
crest. The distance between the buccal bone crest
and the top of the implant was measured, using a
periodontal probe, to the nearest 1 mm. The initial
bone level could be above or below the top of the
implants. After implant placement, submerged healing of at least 3 months was allowed. When the healing abutment was placed, the distance from the bone
crest to the top of the implant was remeasured. The
group of implants that showed no loss of facial bone
height had an average bone thickness, after preparation of the osteotomy site, of 1.8 mm, whereas for
implant groups showing loss of facial bone height, the
average bone thickness was < 1.8 mm. The greater
the loss of bone height, the lower the average thickness of the buccal bone at implant placement. Therefore, the authors suggested that a buccal bone
thickness of around 2 mm would reduce the incidence and amount of vertical bone loss. However,
some remarks are necessary. This study focused on
vertical bone resorption and not on esthetics. There
are no data indicating that resorption of the buccal
bone will lead to soft-tissue retraction. Moreover, it
should be noted that the data were grouped and analyzed according to the amount of facial bone loss/
gain and not according to the initial facial bone thickness. The authors observed that the initial mean facial
bone thickness was smaller for implants that showed
more facial bone resorption at the time of abutment
placement. With respect to these interesting ndings,
one needs to consider the large standard deviations
for mean facial bone thickness, even for implants that
did not show facial bone loss. For the no facial bone
loss group, with an average buccal bone thickness of
1.8 mm, a standard deviation of 1.1 mm was
reported. This means that approximately 95% of the
buccal bone thicknesses were located between 0 mm
(1.8 [2 9 1.1]) and 4 mm (1.8 + [2 9 1.1]). Therefore, these data do not allow the extrapolation or

102

reverse calculation that no facial bone resorption will

occur when the initial buccal bone thickness is
> 1.8 mm.
Moreover, if reverse calculations, based on the
study of Spray et al., (44) are used, the mean vertical
facial bone resorption in the study of Cardaropoli
et al. (17) (which did not consider a correlation
between buccal bone thickness and loss in vertical
height) should have been around 3 mm. However,
Cardaropoli et al. (17) only reported an average of
0.7 mm vertical bone resorption at the time of abutment placement. This discrepancy might be related
to the different implant systems used in both studies.
Additionally, in the study of Spray et al., (44) buccal
bone thickness data from different intra-oral regions
were mixed, whereas in the study of Cardaropoli
et al., (17) only implants in the maxillary incisor
region were considered. It should also be noted that
Cardaropoli et al. (17) positioned the implant shoulder approximately 1.1 mm below the buccal bone
crest. This information is not provided in the study by
Spray et al., (44) or perhaps the large standard deviation values in the study of Spray et al. (44) explain this
discrepancy.
Much enthusiasm has been shown for the immediate implant-placement protocols (type 1) because
they allow a drastic reduction of the length of the
treatment as well as a reduction in the number of surgical interventions (6, 35). Early reports have claimed
that immediate implant placement could prevent the
inevitable bone resorption following tooth extraction.
However, those claims have been dismissed. Vertical
bone changes in relation to buccal bone thickness
after immediate implant placement can be derived
from a case series published by Botticelli et al. (11).
Twenty-one extraction sockets in 18 healthy patients,
located in the anterior region (maxilla and mandible),
received a solid screw implant with an sandblasted
and acid-etched-modied surface (Straumann AG,
Waldenburg, Switzerland) immediately after extraction. The vertical distance between the implant
shoulder and the sandblasted and acid-etched portion was 2.8 mm in the type of implant used. The
implant was placed so that the marginal level of the
sandblasted and acid-etched portion was placed apical to the marginal level of the buccal or the oral wall
of the socket. Before implant installation, the thickness of the buccal wall was measured using a caliper,
1 mm below the bone crest. After implant placement,
the vertical distance between the implant shoulder
and the bone crest, and the horizontal distance
between the implant surface and the outer side of the
bone crest, were assessed. All implants experienced

Buccal bone along implants

a 4-month semisubmerged healing period before

healing caps were placed and bone dimensions were
reassessed. Because Botticelli et al. (11) provided the
measurements for each patient in the case series, the
following data could be derived. No statistical analysis
was performed owing to the limited number of
patients available for analysis. Implants placed in
sites with an initial buccal bone thickness of 1 mm
(n = 8), 1.5 mm (n = 8) or 2 mm (n = 5) exhibited a
change in vertical bone height of, respectively,
0.1  0.8,
0.6  0.4 and
0.3  0.4 mm. For
implants in which the horizontal distance between
the implant surface and the outer side of the bone
crest was 2.5 mm (n = 5, average: 2.4  0.2 mm),
33.5 mm (n = 7, average: 3.3  0.3 mm) or 4 mm
(n = 8), the corresponding change in vertical bone
height was, respectively, 0  0.8,
0.3  0.4 and
0.4  0.8 mm. There was no obvious relationship
between buccal bone thickness or the horizontal distance between the implant surface and the outer side
of the bone crest at implant placement and the
amount of vertical bone resorption at abutment
placement.
These, albeit limited, data are in contrast to the
observations of Chen et al. (19) and Qahash et al.
(42). In an animal study on 12 mongrel dogs,
implants were placed in extraction sockets where
critical-size supra-alveolar peri-implant defects had
been created. A signicant correlation was found
between the initial width of the buccal ridge and
crestal bone resorption. According to the authors,
histometric analysis showed more pronounced
resorption when the ridge width was thinner than
2 mm. However, no statistical analysis to support
that claim was presented. Several modications to
the standard protocol were introduced to enhance
the nal results and limit the extent of bone resorption after immediate implant placement. Primarily,
the use of autologous bone or bone substitutes to
ll in the peri-implant space in the extraction alveole is advocated. Alternatively, it is advised to isolate
the implant and surrounding bone from the soft tissues using resorbable or nonresorbable membranes.
However, some results do suggest that this procedure has no added benet when the distance from
the implant surface to the bony wall is around
11.25 mm (10). Some authors also recommended
the combined use of isolating membranes and lling
material (21). Chen et al. (19) also recently suggested
that the initial thickness of the buccal bone crest
may be a factor in determining the extent of crestal
resorption during the healing phase of immediately
placed implants. This study is, however, not directly

comparable because the buccal bone-thickness data

for immediately placed implants that healed without
grafts and membranes were mixed with data from
implants that healed with grafts or a membrane.
With this in mind, it is still interesting to note that,
in the study of Chen et al., (19) for sites showing a
buccal bone dehiscence after 6 months of semisubmerged healing, the average initial buccal bone
thickness was approximately 50% of the average initial buccal bone thickness of sites that healed without a dehiscence. The vertical resorption in the
former sites was up to three times greater than that
in the latter sites. This made the authors conclude
that the initial buccal bone thickness inuences vertical bone resorption but not horizontal resorption.
Despite the limited amount of data available, this
appears to be in contrast to what could be calculated from the study of Boticelli et al., (11) in which
no correlation could be seen between buccal bone
thickness and vertical bone resorption.
All studies reporting on buccal bone remodeling
after implant placement have relied on direct measurements to assess the evolution of buccal bone. As
a result of this restriction, no measurements were
possible after the stage of abutment surgery. The
only long-term study available is a retrospective
radiographic follow up of 11 implants, 7 years postoperatively, which demonstrated an average loss of
0.3 mm in buccal bone thickness and a 0.6 mm average loss in the vertical dimension (22). However, the
inherent lack of precision of radiographic measurements and the presence of a strong radiopaque
object (the implant) could have had an inuence on
the measurements. Moreover, one has to bear in
mind that the resolution and quality of three-dimensional images, as well as the scattering-reduction
abilities of their software algorithms, were much less
efcient 7 years ago, when the initial images were
produced.
Most studies that investigated buccal bone fate and
critical dimensions were performed on traditional
implant systems. Those implants exhibited a very particular bone-remodeling feature consisting of the formation of a circumferential shallow angular defect
around the implant shoulder, also known as saucerization. The evolution of implant designs and surfaces
has resulted in the fact that most of the actual
implant systems do not show this particular remodeling and do seem to conserve marginal bone more efciently. Therefore, this feature should be borne in
mind when looking at older data and it is a legitimate
to question whether the dimensions considered as
critical in the past hold any value now.

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Merheb et al.

Conclusions
An understanding of buccal bone evolution after
tooth extraction and after implant placement is of
utmost importance, particularly in the highly
demanding esthetic zone. Both animal and human
studies have shown a considerable amount of bone
remodeling following tooth extraction. This remodeling is predominant in the horizontal dimension and
more limited in the vertical dimension. Moreover, the
extent of resorption seems to be a function of the
presence or absence of neighboring teeth, which act
as a buffer against extensive resorption. These elements need to be taken into account by the surgeon
when opting for immediate implant placement.
Therefore, most authors recommend that implants
should be positioned in fresh extraction sockets
slightly palatal and 12 mm subcrestal.
Implants placed in the healed site are subject to
much less bone spatial change. In the initial phase
following placement, modest buccal bone resorption,
of about 0.5 mm, is to be expected. Most authors
consider this as a consequence of bone remodeling
following surgical trauma (49). The long-term data,
presently very scarce (47), seem to suggest that minimal to no bone remodeling is to be expected at later
stages. An initial critical buccal bone thickness of
2 mm has been recommended to prevent vertical
resorption. However, the literature currently available
does not fully back this claim.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

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