Objectives: To compare success rates between the sub‐periosteal prepared (SPP) muco‐periosteal flap and the epi‐periosteal prepared (EPP) mucosa flap and the feasibility of alveoplasty after surgical tooth extractions in patients undergoing/after antiresorptive treatment.Subjects: Patients with an indication for preventive tooth extraction undergoing/after antiresorptive treatment were enrolled over a 24‐month period in a parallel‐group randomized clinical pilot trial and randomly assigned for primary wound closure to either the SPP or the EPP group. The primary outcome was treatment failure 8 weeks after surgery. To assess the feasibility of alveoplasty, necrotic bone changes at the time point of tooth extraction were evaluated.Results: One hundred and sixty patients were randomized to the SSP (n = 82) or the EPP (n = 78) group. One hundred and fifty‐seven patients met the primary endpoint 8 weeks after surgery with five treatment failures for the SPP group (6.3%) and 18 (23.4%) for the EPP group (p = .004). A significant relationship (p < .0001) was observed between symptomatic teeth and non‐vital bone found in 54.8% of all biopsies.Conclusions: The strong superiority of the muco‐periosteal flap as primary wound closure revealed the feasibility and effectiveness of the study. The large number of necrotic biopsies emphasizes the importance of alveoplasty as a preventive measure.