Journal of Alpha Omega International Dental Fraternity Volume 98, Number 2, July 2005

\ '
Alpha Omegan, Volume 98, Number 2, July 200f
SCIENTIFIC ARTICLE
Immediate Placement of Implants into Extraction
Sockets: Rationale, Outcomes, Technique
Stuart J. Froum, D.D.S.
D
ental implants have become a predicable treat-
ment modality for prosthetic restoration of fully
and partially edentulous patients.
l
~* Albrektsson et al.
reported 5- to 8-year implant success rates of 99.1% in
the mandible and 84.9% in the maxilla.
5
These rates
were predicated on a traditional implant approach by
Branemark et al. and Adell et al. recommending a 6- to
12-month healing period after tooth extraction and
prior to implant placement.*' This time frame and the
additional 3 to 6 months required for osseointegration
of the implants, along with the time necessary for
loading and fabrication of the restoration, often
resulted in a treatment time of 1 to 2 years before the
patient received the final implant supported restora-
tion. In an attempt to reduce this treatment time,
implant companies produced textured implants,
which allowed earlier loading.
89
One-stage implants
Stuart Froum, D.D.S.
Stuart Froum received his D.D.S. degree in
1970 from New York University Dental
Center. He completed a general denlistry
residency program at the Fort Hamilton
Veterans Administration Hospital, Brook-
lyn, New York. He received his periodontal
specialty training at the Veterans Adminis-
tration Hospital in New York City. He is a
diplomatc of ihe American Board of Periodontics.
Currently, he holds the position of clinical professor at New
York University Dental Center in both the Department of Peri-
odontics and the Department of implant Dentistry. He is the
director of research in the Department of Implant Dentistry at
New York University Dental Center. Dr. Froum is currently on
the Research Committee of the Academy of Osseointegration. He
is also a member of the Continuing Education Oversight Com-
mittee of the American Academy of Periodontology. He was the
recipient of the Isidore Hirschfeld Award from the Northeast
Academy of Periodonlics and received the Clinicai Research
Award from the American Academy of Periodontology. Hi- has
lectured internationally and published over 70 articles in peer-
reviewed journals. He has contributed chapters in two textbooks.
requiring no second surgery for abutment placement
were also introduced.
l0
~
12
In selected cases, implants
were loaded with provisional restorations on the day
of implant placement
13
"
18
Finally, reports by Schulte et
al. in Germany, Lazzara in the United States and others
established immediate implant placement (IIP) as a
routine clinical procedure.
ll>
"
26
The purpose of this article is to review the ration-
ale, indications, techniques and contraindications for
IIP in extraction sockets.
Rationale for IIP
Literature reviews by Schwartz-A rad and Chaushu,
Chen et al. and Mayfield delineated the advantages
of immediate versus delayed implant placement as
follows
27 29
:
t. Treatment time is reduced.
2. Amount of surgery is reduced.
3. Width and height of the alveolar bone are pre-
served.
4. Ideal implant location can be achieved provided
that the extracted tooth has a desirable alignment
and there is maximum soft tissue support.
As an adjunct to these advantages, several others
accrue, which include less surgical morbidity, a
reduction in treatment expense, if additional regen-
erative techniques (bone grafts and membrane use)
are not applied and better patient acceptance of the
treatment plan.
The biologic advantage often mentioned in the
immediate implant literature is the contention that
the implant will prevent postsurgical bone resorption
seen following tooth extraction as a normal part of
the socket healing.
This resorption has been documented in several
studies and has been reported to result in a 45%
Alpha Omegan, Volume 98, Number 2, July 2005
IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
reduction in the alveolar crest. The majority of this
bone loss occurs over the Brst 6 months following
extraction and the wearing of a denture.
30
'" In the
posterior maxilla, horizontal bone resorption
amounting to 3 to 7 mm after 6 months has been
shown to nearly correspond to the vertical bone
resorption.
52
Two studies by Lekovic et at. and
another by Iasella et al. demonstrated significant
occlusoapical and buccolingual resorption following
tooth extraction in sockets allowed to heal for 4 to
6 months in the absence of any treatment.
3
*'
}b
Changes in the horizontal dimension of these sockets
showed an average loss of 4.5 mm in buccolingual
width and an average 1.5 mm vertical resorption of
the buccal plate of bone.
H
Other articles proposed
that the placement of an implant immediately after
tooth extraction may help preserve the alveolar bone
dimension, allowing placement of longer and wider
implants.
36
"'" However, Covani et al. measured the
buccal to lingual bone at the time of HP {15 implants
in 15 patients) and again at second-stage surgery
6 months later.
39
In spite of the implant being imme-
diately placed, the mean distance in the buccolingual
direction decreased from an average of 10.5 mm
( 1.54) to 6.8 mm ( 1.33). A more recent article by
Covani compared buccolingual bone resorption in
cases of immediate versus delayed (6-8 weeks)
implant placement, the results demonstrated that less
resorption occurred in sockets receiving the immedi-
ate implants (1.9 mm) than in sockets allowed to heal
naturally (3.06 mm).*
1
Although reduced by IIP, this
degree of horizontal resorption may present prob-
lems, especially in the esthetic zone, and will be dis-
cussed later in this article.
Evaluating Outcomes of IIP
Ideally, randomized controlled human trials report-
ing on implant success would present the highest
level of scientific rigor to evaluate the efficacy of IIP.
However, a recent literature review reported that no
studies of this type have been published to date.
28
Therefore, controlled clinical trials, documenting
implant survival, prospective and retrospective case
series and case reports, as well as the few available
histologic reports, are used to assess the results of IIP.
This article will also rely heavily on the literature
reviews and associated consensus statements.
27
"
29
A number of studies reported demonstrate high
levels of survival for implants placed immediately
after tooth extraction (Table 1). However, differences
in technique, use of graft or bone replacement graft
and the nonuse or use of nonabsorbable or
absorbable membrane barriers, soft tissue closure
over the implant, use of implants with different sur-
face textures and sizes and different locations of place-
ment make it difficult to compare and evaluate which
variables are crucial for implant success. In reviewing
these studies, it will therefore be helpful to describe
the materials used and whether soft tissue coverage of
the implant was achieved. Wagenberg and Ginsberg
retrospectively analyzed 1,081 implants placed into
extraction sockets."" Of these, 35% were followed for
I year, 46% followed for 2 to 5 years and 19% for 5 to
II years postloading. No mention was made of the
type of implant surface used. Mineralized freeze-dried
bone was packed around the implants, and a
polyglactin 910 (Vicryl) membrane was placed
extending over the implant 2 to 3 mm beyond the
borders of the alveolar defect. No attempt was made
to obtain complete flap closure over the membrane.
The overall implant survival rate was 95%. Implant
failure was twice as high for maxillary molars as for
mandibular molars. Becker et al., in a prospective
clinical trial, evaluated 134 implants in 81 patients
placed in fresh extraction sockets that were not aug-
mented with barrier membranes or graft materials.
42
All implants had machined (turned) surfaces. Pedicle
flaps were rotated, covering the implant sites. The
authors noted that all implants were placed into good
jaw bone anatomy and quality. The 7-year cumulative
success rate (CSR) was 93.3%.
Schwartz-Arad et al. evaluated 56 immediately
placed implants in 43 patients, all molars, from 1989
to 1996.
+3
They recorded the influence of the follow-
ing parameters on implant failure: gender, arch,
smoking, pre extraction vertical bone loss and implant
length. The 5-year CSR was 89%; for men, it was
84%, and for women, it was 93.5%. The 5-year CSR
was 82% in the maxilla and 92% in the mandible.
Nonsmokers had a CSR of 90%, whereas smokers had
22 Alpha Omegan, Volume 98, Number 2, luly 2005
IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
Table 1 tmplanl Survival Rates in Studies Using Various
Author
Krump&Barnettl991
52
Gelb 1993
26
Mendsdorff-Pouilly et al 1994
s0
Rosenquist & Grenliie 1996"
Becker etal1998
12
Grunderetal 1999
51
Schwartz Arad et al 2000
JB
Schwariz-Arad et al 2000
43
Gomez-Romon etal 2001
46
Wagenberg & Ginsberg 200 V
Prosper et a! 2003^
Covani et al 2004
47
Biancho & Son Filippo 20O4
i3
tolpts
35
51
81
107
NA
43
' 04
591
83
95
116
# of implants
41
50
93
109
134
146
117
56
124
1,081
111
163
116
Immediate Placement Protocols
Surface
Morphology
5
RS
RS
S
s
s
THA
S = 47
HA coated = 9
GBAE
S
SB
SB
AC
PLS
Aogmenf
ND
DFDBA e-PTFE
53 HA
55 AM
NG, 5nRM
NG, NM
NGNM
AB
AB/6 AM 2NAM
AB/nzq
B5N=4
NAMN=17
FDBA+AM
HA, AB
58 NG,
NM 105 AB + AM
NG, NM
Time
3
12.4 rro
30.5 mo
(range l-67mo)
7 yrs
3
5
5 yrs
1-5.65 yrs
1-11 yrs
4
A
l-9yrs
Survival
Rate (%)
92.7
98
92.5
9366
93.3
92.4 max
94.7 mand
96
89
97
95
97.3
97
100
AB = autogenous bone; AC = acid etched; AM = absorbable membrane; GT = grit bhsted; HA = hydroxyapatife coated, NAM = non obsorbable
membrane; NG = no graft. NM = no membrane; RS = rough surface; SB = sandblasted
a CSR of 83%. The authors stated that small autoge-
nous bone chips (from bone adjacent to the implant
site or bur debris) were used "when needed" as a graft
between the socket walls and implant. Six collagen
bioabsorbable and two expanded polytetrafluoroeth-
ylene (e-PTFE) nonabsorbabk membranes were used
"according to the clinical judgment of the operator."
Primary flap closure was obtained according to the
authors "in all cases with bone grafting and mem-
branes." Neither mean implant length and diameter
nor pre-extraction vertical bone loss had any effect on
implant survival. The authors concluded that
although immediate implantation was a predictable
procedure, implant prognosis was better in the poste-
rior mandible than in the posterior maxilla.
Rosenquist and Grenthe evaluated 109 machine-
surface immediately placed implants following
extraction in 51 patients.
14
The mean follow-up
period was 30.5 months (range 1-67 months) and
"no effort was made to fill the gap between the
implant and the surrounding socket gap with a graft."
Closure over the implant varied from using pedicles
or free mucosal grafts to using e-PTFE membranes in
five patients. The implant survival rate was 93.66%.
The survival rates differed depending on whether the
teeth were extracted for periodontal reasons (survival
rate = 92.0%) versus nonperiodontal reasons (sur-
vival rate = 95.8%).
44
Kan et al., in a prospective
study, placed 35 threaded hydroxyapatite (HA)-
coated implants in 35 patients with immediate provi-
sionalization.
43
All implants at 12 months remained
osseointegrated. However, implants were placed only
in sockets with intact labial plates. Midfacial gingival,
mesial and distal papilla shrinkage was recorded to be
-0.55 0.53 mm, -0.53 0.39 mm and -0.39 0.40
mm, respectively. Gomez-Roman et al. placed 124
stepped-screw implants (grit-blasted and acid-etched
surface) in 104 patients immediately following
extraction or implant explanation in a retrospective
study.
46
Grafts included autogenous bone (n = 9) or
bone substitutes {n = 24). Membranes were used "if
the periosteum was not intact." Implant survival rates
remained at 97% from 1 to 5.65 years after implant
placement. The average observation period following
prosthesis placement was 2.6 years, with the longest
observation period, post-implant placement, being
Alpha Omegan, Volume 98, Number 2, July 2005 23
IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
6.3 years. The technique of implant placement was
performed without incisions, and "an attempt was
made to cover the implant with flap closure."
4
*'
Gelb retrospectively reported on 50 consecutively
placed immediate implants in 35 partially edentulous
patients over a 3-year period.
26
All implants had
turned surfaces. Treatment protocol varied depending
on the defect type surrounding the implant. In three-
wall defects and circumferential defects, decalcified
freeze-dried bone allograft (DFDBA) was packed into
the defect and covered with an e-PTFK membrane
contoured to cover the defect margins by 2 mm. In
no-wall defects in which ridge expansion was neces-
sary, DFDBA was used, together with e-PTFE mem-
branes. Treatment and use of DFDBA alone or with a
membrane were not part of a controlled protocol but
were selected according to bone morphology and then
arbitrarily "for comparison." Primary closure was
obtained in 36 cases, secondary closure, including
connective tissue grafts, in 3 cases, free gingival graft
in 1 case, exposed e-PTFE membrane in 6 cases and
exposed DFDBA in 4 cases. The patients were fol-
lowed from August 1989 to April 1993, with a
reported implant survival rate of 98%. No mention
was made as to whether primary closure had any
effect on implant survival. The author concluded that
in three-wall and circumferential defects, "e-PTFE
membranes provide predictable regeneration of bone
and thread coverage."
The variability in technique in the above-
mentioned reviews of immediate implant studies with
no control groups emphasizes the need for compari
son studies to attempt to assess the most efficacious
method of IIP. Covani et al. evaluated IIP in fresh
extraction sockets with and without guided bone
regeneration (GBR).
47
All implants had acid-etched,
sandblasted surfaces. One hundred sixty-three
implants were placed, 95 in the maxilla and 68 in the
mandible. The longest and widest possible implants
were used, and all were placed at the level of the bone
crest. No grafting materials were used for 58 implants,
which presented with no fenestrations or dehiscences
and in which the gap distance did not exceed 2 mm.
The remaining 105 implants with bone fenestrations
or dehiscences or in which the gap between implant
surface and surrounding bone exceeded 2 mm were
grafted with small autogenous bone chips and covered
with bioabsorbable membranes. Flaps were reposi-
tioned to obtain primary wound closure. The 4-year
CSR (calculated from time of implant placement) was
97%. All implants supported single ceramometal
restorations with no splinting. There were no statisti-
cally significant differences in clinical attachment level
or survival of implants treated with GBR and those
treated without GBR.
Schwartz Arad et al. placed a total of 380 implants:
316 machine screw-type, 51 HA-coated screw-type and
13 cylinder HA-coated submerged implants.''
8
Of the
implants placed, 117 were immediate (31%) and 263
were nonimmediate. The authors used small autoge-
nous bone chips (from bone adjacent to the implant
or bur debris) between the implant and socket walls
"when needed." No mention was made regarding flap
closure. The 5-year CSR of all implants was 92%,
which included 96% in the mandible and 90% in the
maxilla. Immediate implants had a higher 5-year
CSR compared to nonimmediate implants (96% vs.
89%, respectively). The main difference was in the
maxilla, where the CSR for IIP was 95% versus 88%
for nonimmediate placement. Prosper et al., in a ran-
domized study, placed 111 implants, 56 in combina-
tion with resorbable HA (HA group) and 55 with a
resorbable polyglycolic and polylactic membranes
(MR group),
49
All implants were sandblasted, self-
threading, pure titanium cylinders with a diameter of
5.9 mm and a length of 11 or 13 mm. All of the fresh
extraction sockets had four walls, and < 2 mm dis-
crepancy existed between the implant head and
cementoename] junction of the adjacent teeth. The
surgeon "tried to appose the two flaps by first inten-
tion." The overall incidence of implant success 4 years
after placement was 97.3% and did not differ signifi-
cantly between the HA group (98.2%) and the MR
group (96.4%).
Mensdorff-Poully et al. retrospectively studied
190 implants, 93 placed immediately postextraction
(64 rough surface, 29 machined-surface) and 97
placed delayed (6 to 8 weeks postextraction), which
included 57 with a rough surface and 40 with a
machined surface.'" In 76 implant placements, a non-
24 Alpha Omegan. Volume 98, Number 2, July 200J
IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
absorbable e-PTFE membrane was used. For 13
implants, HA or autologous bone grafts were used to
fill the gap alone or in combination with GBR. For
114 implants, no membrane was used. After an aver-
age of 12.4 months, 85 of 93 IIP implants were avail-
able for follow-up. For the delayed group, 88 of 97
were available for evaluation. Survival rates were
92.5% for IIP and 94.9% for delayed implants, show-
ing no statistically significant difference in these val-
ues. Grunder et al., in a prospective multicentered
study, evaluated 264 machined-surface implants in
143 patients/
1
One year postloading, a follow-up was
done on 125 patients. One hundred seven patients
were followed for 3 years postloading. Over this
period of 3 years, the implant survival rate was 92.4%
in the maxilla and 94.7% in the mandible. Five meth-
ods of placement were used as follows:
Group 1: 146 implants had IIP.
Group 2: 34 implants were placed after 3 to
5 weeks of healing (no membranes were used).
Group 3: 64 implants were placed with mem-
branes over the extraction socket.
Group 4: 8 implants were placed, and freeze-
dried bone bone grafts or collagen was used.
Group 5: 12 implants were placed with a combi-
nation of the above.
There was no clinical difference in the survival rate
between the immediately placed implants (group 1)
and implants placed with a 3- to 5-week delayed pro-
tocol (group 2).
Krump and Barnctt compared 41 implants placed
immediately after extraction to a control group of 154
implants placed into the anterior mandible without
extraction.
52
All implants had turned surfaces, and no
data were given on the use of any regenerative mater-
ial in the IIP group. The implant survival rate for the
IIP group was 92.7%. Implant survival in the control
group was 98.1%. The differences in survival rates
were not statistically significant.
Bianchi and San Filippo evaluated 116 single
solid-screw immediately placed implants from 1 to
9 years post-implant placement.
51
A subepithelial
connective tissue graft was performed at the same
time as implant placement to achieve wound closure
over 96 implants. No bone graft or membrane was
used. Implant survival rates were 100% for implants
with and without wound closure. The authors noted
that better peri-implant results in terms of stability of
probing depths and esthetics were seen around the
implants receiving the connective tissue grafts.
Although the survival rates of immediately
placed implants appear to be similar to those of
implants placed with a delayed protocol in healed
bone, the question of the bone-to-implant contact
(BIC) that occurs in the gap between the implant
surface and socket wall should be addressed. Carfsson
et al. evaluated titanium implants with initial gap
widths of 0.00, 0.35 and 0.85 mm.
5
"' At 6 weeks, the
control (no-gap group) had bone contact approach-
ing 90%, whereas the 0.35 and 0.85 mm sites had
residual gaps of 0.22 and 0.54 mm, respectively. Knox
et al., in a histologic study, placed eight 3.25 x 10 mm
implants in each of six dogs.
55
Two sites, one on each
side, remained as a control, whereas 0.5, 1.0 and
2.0 mm defects were created circumferentially around
the test implants. One side received HA-coated
implants, and the other side received grit-blasted tita-
nium (GBT) implants of similar dimension. All dogs
were sacrificed at 8 weeks. The HA and GBT implants
had levels of osseointegration similar to those of the
control group and around implants with the 0.5 mm
gap defects. For all other defects, the HA group
showed more coronal levels of osseointegration and
smaller residual defects than did the GBT group.
However, in the larger defects (2.0 mm gap), HA and
GBT implants showed larger residual defects and
more apical levels of osseointegration than the con-
trots. The authors concluded that "combination ther-
apy using guided tissue regeneration, bone grafts, or
both may be indicated in sites with larger bone gaps."
Barzilay et al. histologically compared levels of
bone integration of immediate implants with
implants placed in healed (control) sites in four mon-
keys 7 months postloading (13 months postimplanta-
tion).
56
Histologic Findings from 30 immediate and
9 control turned-surface implants were compared.
The percentage of bone integration was similar in
both groups. However, the authors noted that "bone
patterns peripheral to the interface region differed,
Alpha Omegan, Volume 98, Number 2, July 2005 2"
IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
suggesting that special consideration be given to
implants placed in the posterior regions of the maxilla
and mandible." They suggested using wider implants
or implants in narrow posterior ridges to allow the
immediate implants to engage cortical bone. This has
implications in the discussion of immediate implant
indications and techniques later in this article.
Akimoto et al. evaluated the effect of gap width
on bone healing around commercially pure titanium
machined-surface implants placed into simulated
extraction sockets of varying widths in 10 mongrel
dogs.
17
All implants were 10 mm long by 3.3 mm in
diameter. Gap sizes of 0.5, 1.0 and 1.4 mm, all 6 mm
deep, were created for implant placement. Controls
had no gaps. All dogs were sacrificed at 12 weeks, and
the percentage of BIC was measured histologically. As
the gaps widened, the amount of BIC decreased and
the point of the highest BIC shifted apically. These
changes were statistically significant for the gap areas
and not statistically significant in the 4 mm of apical
native bone that surrounded test and control
implants. Clinically, the simulated extraction socket
defects healed with complete bone fill regardless of
flap size. However, the width of the gap at the time of
implant placement had a significant impact on the
histologic percentage and height of BIC. Similar
results in one human were reported by Wilson et al.,
who placed five titanium plasma-sprayed implants."*
One served as the control in native bone, and four
were placed in immediate extraction sockets. The
results showed that all implants integrated with vary-
ing percentages of direct BIC. All implants were
removed in block sections 6 months postplacement.
The BIC of the control implant was 72.14%. The
mean BIC of the two immediate implants with small
peri-implant bone defects at the time of placement
(horizontal defect dimension [HDD] = 1.5 mm) was
approximately 50%. Two immediate implants on
which the HDD measured more than 4 mm and in
which e-PTFE membrane barriers were used and sta-
bilized by the cover screws showed a mean BIC of
17%. The authors concluded that "the horizontal
component of the defects was most critical in dictat-
ing the final amount of bone-implant contact during
a 6 months healing period." They further concluded
that in spite of this small sample size, membranes
were not necessary in sites in which the HDD does
not exceed 1.5 mm.
58
Another histologic study in a
dog model by Novaes Jr et al. looked at the effect that
periapical pathology of the extracted tooth had on the
success of the immediately placed implant.
3
'' Nine
months after the induction of periapical lesions,
experimental and control (no lesions) teeth were
extracted, and sockets were debrided and rinsed with
50 mg/mL solution of tetracycline hydroxide. Twenty-
eight IntraMobile Cylinder (IMZ) implants were
placed, 15 experimental and 13 controls. These
implants were slightly larger than the extracted roots.
Flaps were sutured over all implants to obtain com-
plete coverage. AH dogs were sacrificed after
12 weeks. The mean percentage of BIC around the
experimental implants was 28.6 24.8%, with a
range of 25 to 100%. The mean percentage of BIC
around the 12 control implants was 38.7 25.5%,
with a range of 3.9 to 91.2%. The difference was not
statistically significant. The conclusion of this study
supported the results of clinical Findings in humans:
that chronically infected sites, those showing peri-
apical pathology, may not be contraindicated for IIP
if meticulous cleansing and debridement are per-
formed and appropriate antibiotics are administered
pre- and postoperatively.
60
Indications and Techniques of IIP
A review of various implant site classifications and
indications for IIP was presented by Saadoun and
Landsberg.
61
The classification system suggested by
Garber and Belser proposed IIP in class I sites (dehis-
cence of less than 5 mm with no loss of hard or soft
tissue) and class II sites (dchiscence equal io 5 mm
demonstrating hard and soft tissue collapse in a buc-
colingual direction only with no alteration in vertical
height).
62
In both cases, the authors recommended
avoiding flap elevation, the use of a barrier membrane
and a bone graft where necessary (to support the
membrane), and sealing the socket orifice with an
epithelial connective tissue graft." The essential
requirement mentioned was the attainment of pri-
mary implant stability by drilling the osteotomy site 4
to 5 mm apical to the alveolar socket. For class III sites
Alpha OmL'finn, Vo l u me 9S, Nu mb e r 2, Jul y 2005
IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
(dehisccnces of greater than 5 mm, characterized by a
notable collapse of hard and soft tissue with no signif-
icant loss of vertical dimension) a delayed approach
was recommended with rebuilding the ridge and plac-
ing implants 6 to 9 months postsurgery, or IIP using a
bone graft, membrane and connective tissue graft.
The decision to use delayed placement or IIP would
be dependant on the ability to achieve primary
implant stability and how critical the esthetic result.
In class IV sites, representing severely compromised
sockets with insufficient buccolingual bone and no
vertical bone loss, the authors suggested a staged
approach using autogenous bone grafts and GBR. The
delayed implant placement would be performed 6 to 9
months postsurgery using a connective tissue graft.
Although these approaches are clearly delineated, the
more a clinician combines and compresses the various
regeneration procedures in efforts to expedite treat-
ment, the greater the risk and severity of surgical heal-
ing and complications.**
4
A recent consensus report based on available lit-
erature obtained from a thorough MEDI.INE review
of studies published between 1990 and June 2003,
combined with the clinical experience of the consen-
sus group, classified and defined four different types
of implant placement, stating the advantages and dis-
advantages of each.
28
Type 1 was defined as 'implant
placement immediately following tooth extraction as
part of the same surgical procedure." Type 2 was
defined as placement of the implant following com-
plete soft tissue coverage of the socket (typically 4 to
8 weeks postsurgery). Type 3 was defined as implant
placement "following substantial clinical and/or radi-
ographic fill of the socket (typically 12-16 weeks)."
Type 4 was defined as implant placement in the
healed site (typically more than 16 weeks).
The indications for a type 1 placement (IIP) were
based on the ability to attain primary implant stabil-
ity with an "appropriately sized implant in an ideal
restorative position." Although the majority of com-
parative data, albeit limited, show that the survival
rate for implants placed immediately following
extraction of teeth with local pathology is similar to
that of implants placed in healed ridges, factors such
as soft tissue and bone quantity and quality, as well as
the presence of pathology and the condition of the
adjacent teeth, enter into the decision of timing of
implant placement. For example, in a patient with a
thin Biotype (thin scalloped gingiva) in whom the
buccal plate is lost or anticipated to resorb, esthetics
becomes a primary consideration as to implant tim-
ing. If IIP is performed, a barrier membrane and
supporting graft are recommended. This presents
more risk for complications, leading to an unaccept-
able esthetic result. In these cases, delayed placement
(types 2-4) may be indicated to allow placement in
greater bone quantity with improved soft tissue cov-
erage. A thick Biotype (thicker, less scalloped gingival
architecture) causes less of a risk of buccal plate
resorption, especially where the plate is intact follow-
ing extraction. These cases present a better indication
for IIP. The above guidelines may serve as a founda-
tion for more closely analyzing factors that may con-
tribute to the success of the IIP procedure from both
functional (implant survival) and esthetic (implant
success in the esthetic zone) aspects.
Reviews of the literature on IIP have concluded
that there is no consensus on whether the use of bone
grafts, bone replacement grafts and/or membranes in
combination with implants placed in extraction
sockets yields better results than those obtained with
unaugmented immediately placed implants.
2
'"
2
''
Schropp et al. noted that following placement of
46 acid-etched Osseotite implants, 23 with an imme-
diate (10 days postextraction) and 23 with a delayed
(3 months after extraction) protocol in both groups,
a higher degree of bone healing was achieved in the
infrabony defects surrounding the implant (> 60% of
depth) than in dehiscence-type defects (approxi-
mately 25% h
6
' These results were reported using
only autogenous bone chips grafted to the exposed
implant threads in cases of dehiscences that were pre-
sent in the delayed implant group. The potential for
spontaneous bone healing in three-wall infrabony
defects with 1 to 3 mm gaps was approximately 70%.
This inability of dehiscence-type defects to heal with
bone grafts alone would indicate the need for barrier
membranes in these cases. When using barrier mem-
branes, reports of membrane exposure leading to
complications such as bone loss, infection and even
implant loss ranging between 8 and 100% have been
published.
6
*
1
-
67
However, Lekholm et al., in a canine
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IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
study, reported greater amounts of bone with mem-
brane-treated implants, with late removal of the
membranes resulting in maximal bone formation.
68
Considering the above results, the clinician
should base the decision to perform IIP on the
anatomy of the extraction socket, the availability of
bone apical to the socket and the quality of soft tissue
surrounding the socket. The possible esthetic com-
promise of the final restoration should be weighed
against the advantage of a decrease in the number of
surgeries, cost and delivery time of the final restora-
tion. A successful result with IIP is most predictable
when an atraumatic extraction of the hopeless tooth
can be accomplished in a flapless surgery, preserving
the hard and soft tissue morphology of the extraction
socket. In the esthetic zone, it is essential to maintain
the interproximal papillae and interproximal bone on
the adjacent teeth. Predictability for favorable esthetic
outcomes is also increased in patients with a flatter
and thicker gingival architecture (thick Biotype)
(Table 2 and Figures 1 to 7). Thorough socket debridc-
ment is also essential, and although success has been
reported with IIP in infected sockets,
59
'
60
in terms of
biologic principles and predictability, a delayed
implant approach in these cases may be prefer-
able.-
73
Osteotomies should extend 4 to 5 mm apical
to the apex of the socket. In the maxillary anterior
area, these osteotomies should be guided with a sur-
gical stent, be made on the lingual incline of the
extraction socket and be aimed toward the ideal cin-
gulum area of the replaced tooth. The implant should
be placed in such a way that it does not place pressure
on the buccal plate and cause rcsorption. In cases in
which the gingiva is highly scalloped and the buccal
plate is thin, maintaining a small gap < 1.5 mm
between the buccal surface of the implant and buccal
plate is advisable. In the mandibular anterior and
premolar areas, the implant should be slightly larger
than the socket to eliminate any gap between the
implant and the socket walls (Figures 8 to 14). In the
posterior areas, the implant should be placed in the
intcrseptal bone or, if this bone is missing, in the
socket with the greatest number of surrounding walls
in a position to engage cortical bone. A wider
implant or two implants may be indicated depending
on posterior socket morphology. All implants must
exhibit primary stability after placement. Limiting
the gap between the immediately placed implant and
the socket wall to < 2.0 mm allows implant place-
ment without the use of filling materials and barrier
membranes. This decreases the potential complica-
tions of the immediate implant procedure.
47
'
58
'
69
This
was demonstrated in a study by Paolantonio et al. in
2001 with 96 experimental titanium plasma-sprayed
mini-impfants placed, 48 in extraction sockets with
horizontal defects < 2 mm and 48 into mature bone
to serve as controls without the use of grafts or mem-
branes and with primary closure.
69
Reentry at
6 months showed complete fill of all defects. Histo-
logic examination showed no statistically significant
differences between test and control sites in the per-
centage of 13IC and the initial level of BIC. Thus, with
Table 2 Risk Factors and Prognosis for
Factors
Socket morphology
Biolype
Ability to disinfect socket
Smoker > 1 pock/d
Buccal dehiscence 2 mm
Buccal dehiscence > 2 mm
Gap between implant and socket < 2 mm
Gop between implant and socket z 2 mm
Immediate Implant Placement
Good
4 walls
Thick or thin scalloped
Good
Good
NEZ
EZ mem
NEZ Mem/BG/CT
EZ RA Delayed implant
Good
NEZ mem/BG
EZ RA/deloyed implanf
Fair
3 walls
Thin scalloped
Fair
Fair
Mem/BG
Mem/BG
Mem
Mem, mem/BG + CT
High Risk
2, l,0walis
Thin
Poor
Poor
Mem/BG
RA-deloyed implant
Mem/BG/CT graft
RA-delayed implant
BG = bone graft or bone replacement graft; CT = subepilhelial connective tissue graft; EZ = esthetic zone; Mem barrier membrane; NEZ = non-
esthetic zone; RA = ridge augmentation.
28 Alpha Omcgan, Volume 98, Number 2, July 2005
IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
a gap of < 2 mm, especially in circumference defects, also be accomplished using larger-diamctcr
complete bone fill can be obtained without the implants.
47
However, recent research has shown that
adjunctive use of bone and membranes.
6
^ This may a 2 to 3 mm distance between natural teeth and
Figure 1 Clinical view of o maxillary deciduous molar prior
to extraction (site 1 3) (case by Dominick Galasso).
Figure 2 Periapical radiograph of a hopeless
tooth prior to extraction.
Figure 3 Occlusal view of the fractured tooth in Figure 1. Figure 4 Clinical view following extraction,
immediate implant placement and temporizaHon.
Figure 5 Occlusal view of a healing implant. Fi gure 6 Radiograph of a Final implant
supported restoration.
Alpha Omegan, Volume 98, Number 2, July 2005 29
IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
Figure 7 Clinical view of an implant-supported restoration
with intact interproximal papillae.
Figure 8 Clinical view of four hopeless mandibular incisors
prior to extraction (case by Dennis Tarnow).
Figure 9 Radiograph of teeth in Figure 8.
implants and a minimum 3 mm distance between
idjacent implants is necessary to preserve the inter-
dental (intertmplant) papillae.
70
-
71
In light of these findings, smaller-diameter
implants may be indicated in the esthetic zone to
maintain the necessary 2 to 3 mm implant-to-tooth
relationship. In cases in which the gap between
implant surface and socket wails exceeds 1.5 to
2.0 mm, bone graft or bone replacement graft materi-
als, together with barrier membranes, may be indi-
Figure 10 Atraumatk flapless extraction is performed to
preserve the socket walls.
cated. However, in a 7-year follow-up study on imme-
diately placed implants, Schwartz-Arad and Chaushu
used autogenous bone chips to fill peri-implant
defects without using barrier membranes and showed
a high survival rate, with very few complications.
7
-
When immediate implants can be placed within the
alveolar confines, high survival rates were reported
without using grafting materials or barrier mem-
branes.
42
The small circumferential defects between
implants and surrounding bone walls were filled with
blood and then covered by a pedicle flap. The defects
filled with bone, and a 93.3% implant survival rate
after 4 years was reported. The use of barrier mem-
branes appears to be advantageous when attempting
to regenerate a dehiscence or buccal fenestration with
exposed implant threads. Absorbable membranes are
Alpha Omegan, Volume 98, Number 2, July 2005
IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
Figure 1 1 Three immediate implants are placed in the
mandibular left lateral incisor and right central and lateral
Figure 12 Final restoration prior to insertion.
mcisors.
Figure 13 Radiograph of the final supported restoration.
less prone to bacterial contamination, especially when
exposures occur, and are therefore better suited for
these purposes. They also exhibit a lower incidence of
premature membrane exposure (Figures 15 to 20).
7i
'
74
A recent study by Corneiini et al. compared
6-month hard and soft tissue healing around imme-
diately placed implants using two different groups.
7
'
The test group received Bio-Oss and Bio-Gide mem-
Figure 14 Clinical view of tfie restoration 1 year posiioading.
branes to treat the gap (defect around the implant),
whereas the control group received a Bio-Gide mem-
brane alone. Treatment outcomes showed no differ-
ences between test and control implants in radi-
ographic bone levels. Both showed no change from
baseline levels and no difference in probing attach-
ment level. However, at the proximal site, the soft tis-
sue margin was located 2.6 mm more coronally than
the implant shoulder in the test group compared
with 1.3 mm in the control group. The correspond-
ing buccal figures were 2.1 and 0.9 mm in the test
and control groups, respectively. Thus, the use of
anorganic bovine bone matrix to support the barrier
membranes resulted in better soft tissue support for
the final restoration. This, again, is critical in the
esthetic zone. A recent prospective study of 62 single
IIP in 62 patients used five randomly selected groups,
one with a nonabsorbable membrane only, two with
Alpha Omegan, Volume 98, Number 2, July 2005
IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
Figure 15 Radiographic view of the hopeless maxillary left Figure 16 Socket with deficient buccal plate following
central incisor (case by Borry Wagenberg). extraction.
Figure 17 Use of mineralized bone and an absorboble
membrane to treat the dehiscence defect associated with IIP.
Figure 1 8 Six months post IIP, prior to abutment placement.
Figure 20 Clinical view of the restoration 5 year postioading.
Figure 19 Final implant prosthesis 5 years
postloading.
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IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SOCKETS:
RATIONALE, OUTCOMES, TECHNIQUE
an absorbable membrane only, group 3 with an
absorbable membrane and autogenous bone, group 4
with autogenous bone alone and group 5 with no
membrane or bone. The best outcomes in terms of
complete bone fill of the defects around the HP was
obtained in the group treated with an absorbable
membrane and autogenous bone.
76
The immediately placed implant should be posi-
tioned 0 to 3 mm apical to the crestal bone. If a
dehiscence exists, the implant may be placed 3 mm
apical to the cementoenamel junction of the adjacent
teeth margins. Primary flap closure may be obtained
by periosteal releasing and vertical incisions to allow
flap advancement. Other methods, including rota-
tional flaps, splint flaps or connective tissue grafts,
have also been recommended.
77
'
81
However, high lev-
els of implant survival have been reported without
primary flap closure, providing that an absorbable
membrane was used to cover the implant." In the
esthetic zone, a soft tissue graft placed over the
implant and membrane barrier (where used) may
avoid any additional mucogingival surgical proce-
dures necessary to reestablish a lost vestibule and
repair the soft tissue-implant morphology.
In cases in which implant placement is required
in a highly esthetic zone, in a patient with a high
smile line, IIP may be contraindicated. This is espe-
cially true when a thin, highly scalloped gingiva (thin
Biotype) is present. Based on studies demonstrating
horizontal^ and midfacial"
15
buccal plate and gingival
resorption 6 to 12 months post-IIP, the risks of a
compromised esthetic result would, in my opinion,
contraindicate this approach. A delayed approach,
type 2 or 3, would allow better tissue control. More
over, if soft or hard tissue augmentation were neces-
sary, it may be performed more predictably prior to
implant placement. Other contraindications for IIP
would include the inability to place the implant in an
ideal restorative position because of a compromised
socket architecture following tooth extraction.
Antibiotic coverage pre- and postsurgery appears
to be an important part of most IIP protocols. The
use of amoxicillin (1 to 2 g) 1 hour preoperatively
and 500 mg three times daily for 7 to 10 days post-
surgery is recommended by most authors. Postsurgi-
cal use of chlorhexidine rinses twice daily for at least
3 weeks is also recommended. Many authors recom-
mend taking one ibuprofen tablet 800 mg four times
a day for 7 to 10 days postsurgery to decrease pain,
inflammation and swelling.
27
In conclusion, high implant survival rates have
been reported for implants placed in fresh extraction
sockets (comparable to implants placed in healed
ridges).
27
"
29
Moreover, the advantages afforded by IIP
make it a valuable modality in implant therapy for
both the clinician and the patient. However, as
emphasized in a recent literature review, the many
variations in treatment protocol for immediately
placed implants, together with the paucity of long-
term studies of implant success, indicate the necessity
for controlled clinical trials to establish predictable
and reproducible techniques and results.
28
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RATIONALE, OUTCOMES, TECHNIQUE
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