Continuing Education

Course Number: 169

Immediate Dental Implant

Placement: Technique, Part 1
Authored by
Gary Greenstein, DDS, MS, and John Cavallaro, DDS

Upon successful completion of this CE activity 2 CE credit hours may be awarded

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contact their state dental boards for continuing education requirements.

Immediate Dental Implant
Placement: Technique, Part 1
Effective Date: 1/1/2014 Expiration Date: 1/1/2017
LEARNING OBJECTIVES
After participating in this CE activity, the individual will learn:
Indications and contraindications for immediate implant
placement.
Practical suggestions for immediate implant placement.
ABOUT THE AUTHORS
Dr. Greenstein is a professor in the
department of periodontology at the
College of Dental Medicine, Columbia
University, New York, NY. He maintains a
private practice in surgical implantology
and periodontics in Freehold, NJ. He can
be reached at ggperio@aol.com.
Disclosure: Dr. Greenstein reports no disclosures.
Dr. Cavallaro is a clinical associate
professor of the implant fellowship
program and prosthodontics of Columbia
University, NY, and is in private practice of
surgical implantology and prosthodontics
in Brooklyn, NY. He can be reached at
docsamurai@si.rr.com.
Disclosure: Dr. Cavallaro reports no disclosures.
INTRODUCTION
Immediate dental implant placement refers to insertion of an
implant directly after a tooth is extracted, whereas delayed
positioning occurs at some later time. The concept of placing
implants immediately after tooth removal was introduced in
the 1970s.1 Currently, widespread acceptance of this
procedure is due to its high survival rate.2,3 However,
placement of immediate implants in different regions of the
mouth and under diverse conditions can be challenging. This
2-part article addresses issues relevant to immediate
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Continuing Education
implants (part 1), and provides practical clinical information
for positioning immediate implants in different sections of the
mouth (part 2).
BACKGROUND INFORMATION
Classification of Extraction Sockets
The following classification system identifies clinical
scenarios related to immediate implant placement4
(classification of socket type is dependent on information
obtained with a periodontal probe, visual, and radiographic
assessments):
l Type I: The bony socket is intact, and the soft-tissue
form is undisturbed.
l Type II: The bony socket is intact in the coronal aspect
of the socket, but a fenestration is present in the apical
area. The soft tissue remains intact and undisturbed.
l Type III: Bone loss is present in the coronal aspect of the
socket. The soft tissue remains intact and undisturbed.
l Type IV: Bony defects exist in conjunction with soft-
tissue deformity.
Indications and Contraindications for Immediate
Implant Placement
There are a series of decisions that need to be made prior to
proceeding with immediate implant placement. First, the
socket type needs to be assessed and categorized as shown
above. Type I and usually Type II (depending on extent of the
defect) sockets are candidates for immediate implant
placement and require preservation of adjacent tissues
around an immediate implant. Types III and IV sockets
frequently warrant delayed placement and soft- or hard-
tissue augmentation prior to implant insertion. This paper
mainly focuses on surgical management of Type I cases.
Management of cases (immediate versus delayed implant
placement) requires both a surgical and prosthetic
perspective. Prior to initiating therapy, a patient should be de-
fined as having a high or low risk of attaining an excellent
esthetic result, especially in the esthetic zone. Table 1 outlines
critical determinants for evaluating patients.5
The main advantages of immediate implant placement
are that they save time and there are fewer patient visits.
There are numerous indications for tooth replacement with
an immediate implant when an adequate amount of bone

Immediate Dental Implant Placement: Technique, Part 1
and soft tissue are available to support it: deciduous
tooth, endodontic failure, caries, deep probing depths
due to periodontitis, vertical root fracture, and
idiopathic root resorption. Contradictions to inserting
immediate implants include inadequate height or
width of bone, lack of soft tissue, adverse location of
nerves, proximity of adjacent teeth, failure to achieve
primary stability, and inability to attain a restoratively
reasonable position, angulation or sink depth of the
implant.
Immediate Implant Survival Rates
Implants immediately placed into fresh extraction
sockets and healed ridges have similar survival rates
(97.3% to 99%).2,3 Furthermore, immediate implants
inserted into infected sites6,7 or locations with
periapical lesions have comparable survival rates to
implants placed into healthy ridges.8 However, these
studies did not delineate the amount of bone grafting that
was performed or extent of infections that were present.
Healing Phase and Bone Loss
Typical Healing of an Extraction SocketSix months after
tooth removal, which includes flap elevation, the extraction
sockets manifest a mean 1.24 mm vertical bone loss (range
0.9 to 3.6 mm). Usually there is approximately 3.79 mm
horizontal bone decrease (range 2.46 to 4.56 mm).9
In contrast, extractions of teeth with no flap demonstrate a
reduced amount of horizontal10-12 and vertical bone loss.13-16
However, others suggest there is no difference in the amount of
vertical osseous resorption if procedures are done flapless or
with a flap when placing implants, but these studies did not
necessarily address immediate implants.17-21 Bone reduction
after flapless extractions may be due to elimination of the blood
supply from the periodontal ligament (PDL). Differences in
osseous resorption rates in the above studies may also be
attributed to buccal plate thickness (thicker plates resorb less).22
Nevertheless, especially in the esthetic zone, it is suggested that
immediate implants be placed without elevating a buccal flap to
preserve bone and avoid soft-tissue recession.
Socket Healing After Immediate PlacementMany
studies verified that immediate implant placement is
accompanied by bone loss. This was corroborated in
Continuing Education
Table 1. Diagnostic Assessment in Determining High and
Low Risk of Attaining an Excellent Esthetic Result5
Clinical Feature Low Risk High Risk
1. Level of the free Coronal to cemento- Even or apical to CEJ
gingival margina enamel junction (CEJ)
2. Gingival formb Flat scalloped High scalloped
3. Biotypec Thick Thin
4. Tooth shaped Square Triangular
5. Position of High crest Low crest
osseous creste
6. Facial lingual Lingual Facial
plane of toothf
aA coronal free gingival margin provides a margin of error for some minor recession that may occur.
bFlap scalloped gingival contours recede less than high scalloped contours.
cThin biotype will manifest more recession than thick biotypes.
dTriangular teeth manifest more recession than square teeth.
eIf the bone crest is > 3 to 4 mm apical to the free gingival margin perform delayed implant placement.
fTeeth in lingual position have thicker bone and thicker gingiva, if prominent buccally the bone is
thinner and recession occurs more often.
dogs23-25 and human clinical trials.26-27 Commonly, there is
a reduction of vertical bone height and even a greater
amount of horizontal bone loss.23,27 The quantity of bone
resorption is larger on the buccal than the lingual side of an
implant, since the buccal plate is usually thinner.28,29 The
degree of bone reduction is related to numerous factors
(Table 2).12-15,21,30-37
Immediate Implants Help Preserve Vertical Bone
HeightAmong patients who receive immediate implants,
the amount of bone resorption during the first year after tooth
extraction38-41 appears to be less than when teeth are
removed and no implants are placed.42-44 This is based on
investigations that did not directly compare patients that had
both therapies. For instance, 1.0 to 1.5 mm vertical bone
height is usually lost after an extraction, when a flap is
elevated42-44; however, vertical bone loss noted the first year
after immediate placement was 0.6 mm with Tioblast
fixtures,38 0.4 mm for Astra Tech (DENTSPLY Implants),39
0.37 for NanoTite Prevail (Biomet 3i),40 and 1.1 mm of bone
loss occurred after nonocclusal and early loading with
Osseotite (Biomet 3i) implants.41
Other data also support the contention that immediately
placed implants preserve bone. When the amount of
osseous resorption that occurs after immediate and delayed
implant placement is compared, the data demonstrate that
there are no differences in the quantity of bone lost.45-47
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Immediate Dental Implant Placement: Technique, Part 1

Table 2. Factors Affecting Healing of the Bone and
Adjacent Soft Tissue12-15,21,30-37
1. Flap elevationElevation of a flap and disturbance of blood supply
can result in bone resorption.12-15
2. Size of horizontal bone gapGaps < 2 mm fill spontaneously
without bone grafts or barriers, submerged or not submerged.30
3. BiomaterialsGraft materials included autogenous bone,
demineralized freeze-dried bone, and hydroxyapatite. All the techniques
provided clinically acceptable defect resolution.31
4. Thickness of the buccalSpray et al32 noted that osteotomies in
healed ridges with a 2 mm thick buccal plate do not normally
resorb bone vertically, whereas osteotomy walls < 2 mm wide
demonstrate bone loss (these data may be true for socket walls,
but it has not been investigated). It was advised by several authors
that if the buccal bone thickness is not one to 2 mm thick, hard-
tissue augmentation was recommended to maintain the level of the
osseous crest.32,33
5. BuccolingualThe closer the implant is to the buccal plate, the
greater the amount of bone resorption that occurs.21,34
6. Position of implantsLarge implants which encroach on the
buccal plate result in additional bone loss as opposed to retaining
bone. Implants placed to buccally manifest 3 times more recession
than lingually placed implants (1.8 mm versus 0.6 mm).35
7. Number of bony wallsThe most favorable healing is in 3 walled
defects,36 which is similar to the gap between the bone and the implant
surface. If left undisturbed, the gap will fill in with a clot and bone.
8. Implant surfacesTextured implant surfaces provide greater
surface area and improved levels of osseointegration compared to
machined surfaces.
9. Role of adjacent teethImmediate implants placed in several
adjacent sockets manifested more bone loss than implants which were
inserted into a single socket adjacent to healthy teeth.37
However, these investigations made evaluations with respect
to the amount of bone reduction several months after
immediate or delayed placement. The baseline for evaluating
the preliminary bone height was assessed on the day of
implant insertion. Researchers did not consider that with
delayed placement, bone loss occurred postextraction and
before delayed insertion of an implant. Therefore, it can be
deduced that delayed placement resulted in a larger degree
of bone loss than immediate implant insertion.
Table 3. Furcation Location Relative to the
Cemento-Enamel Junction (CEJ)48
Tooth Furcation Location Distance to CEJ
Maxillary first molar Buccal 4 mm
Mesial 4 to 5 mm
Distal 5 to 6 mm
Maxillary second molar Buccal 6 mm
Mesial and distal > 6 mm
Mandibular first Buccal 3 mm
and second molar Lingual 4 mm
vally, clinicians preference). As indicated, in the esthetic
zone, a buccal flap should not be elevated to reduce
recession. Posterior teeth with multiple roots should be
sectioned with burs prior to extraction to avoid fracturing the
buccal bony plate or the furcation bone. To facilitate removal
of single-rooted teeth or roots of teeth that do not elevate
quickly, a skinny bur can also be used. Sink the bur into the
PDL, press against the tooth, and circumscribe the tooth for
270, but avoid the buccal aspect (Figure 1). Burring severs
the PDL, creates space (preferably at the expense of the
tooth structure), and facilitates tooth removal. The sockets will
heal normally. If the bone turns black when using a bur, it is
being burned and the amount of water needs to be increased
or a new bur is needed. Table 3 delineates locations of
furcations and provides guidelines with respect to how deep
to drill into a multirooted tooth to separate roots.48
After a tooth with a healthy periodontium is removed, it
is not necessary to curette the PDL to ensure that the
socket fills with bone. Similarly, if a tooth with a healthy
periodontium is extracted prior to immediate implant
placement, it is not essential to remove the PDL prior to
implant insertion to attain bone fill around a dental
implant.49 On the other hand, if pathosis exists, then all

PRACTICAL SUGGESTIONS FOR IMMEDIATE

IMPLANT PLACEMENT Figure 1. Clinical view.
Atraumatic Tooth Removal Prior to Implant Insertion The diamond bur is
inserted into the
Teeth need to be removed atraumatically to preserve the periodontal ligament
maximum amount of bone before immediate implant space of tooth No. 9.
The diamond can be
placement. The clinical situation will dictate if the tooth used mesially, distally,
should be removed flaplessly (eg, if it is broken subgingi- and palatally.

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 Continuing Education

Immediate Dental Implant Placement: Technique, Part 1

granulomatous tissue should be removed. At a b
present, no studies have compared the healing
response of bone around immediately placed
implants with respect to bone fill related to the
absence or presence of the PDL.

Width and Length of an Implant to Attain

Primary Stability
Depending on the size of the extracted tooth
and the implant to be placed, somewhere
along the root surface, the implant will
usually exceed the diameter of the root and
provide mechanical retention of the implant.
This retention and/or extension of the
Figure 2a. Radiograph of structurally unsound tooth No. 4. The tooth reaches the sinus.
osteotomy and placement of the implant Figure 2b. Radiograph demonstrating insertion of an implant with a diameter wider than the
beyond the apex of the extracted tooth provide socket. In addition, aggressive apical threads engage the bone lateral to the socket walls.
primary implant stability. It is advisable to place an implant a more subcrestally, since there may be an increased amount
minimum of 3 to 5 mm into bone to attain primary stability if of bone resorption. The amount of vertical bone loss can be
mechanical retention cannot be achieved laterally (Figures decreased with platform switching. Atieh et al52 reported that
2a and 2b). Occasionally, it is possible to place a tapered bone loss with versus without platform switching after
implant into an extraction socket with minimal to no immediate implant placement was respectively, 0.05 mm to
osteotomy preparation, thereby relying on the threads 0.99 mm versus 0.19 mm to 1.67 mm.
engagement of the bone lateral to the socket walls. As a general rule, platforms of immediate implants
should be placed 2 to 3 mm below the gingival margin
Apicocoronal and Horizontal Placement of (Figures 3a to 3e).53 This may or may not correlate with
Immediate Dental Implants being 2 to 3 mm below the cemento-enamel junction (CEJ)
In general, immediate implants should be placed one mm of the adjacent teeth. Therefore, if recession occurred on
subcrestally as viewed from the midpoint of the labial plate the adjoining teeth, using the CEJ as a guide will provide a
to account for vertical bone height resorption (the implant poor esthetic result.
often will be deeper interproximally).50,51 If the buccal or Horizontally, implants should not touch the buccal plate of
lingual plates of bone are thin, the implants should be placed bone29 because there is a horizontal zone of influence, and if

a b c d e

Figure 3a. Radiograph of Figure 3b. Clinical view of
structurally unsound tooth an immediately placed
No. 12 to be extracted. implant at site No. 12. The
sink depth is approximately
4 mm apical to the free
gingival margin.
Figure 3c. Radiographic Figure 3d. Intraoral clinical view of Figure 3e.
view of implant at site the definitive restoration at insertion at Radiograph of the
No. 12. site No. 12. definitive restoration
at site No. 12.

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Immediate Dental Implant Placement: Technique, Part 1

Table 4. Possible Therapies Available to Treat the Buccal Gap After Immediate Implant Placement:
With and Without Flap Elevation56
A. WITH FLAP ELEVATION ADVANTAGE DISADVANTAGE
1. NO ADDITIONAL TREATMENT (NO BONE GRAFT OR BARRIER USED)
a. Flap placed over the defect Covers defect This may require flap advancement
Increased morbidity (edema and ecchymosis)
Soft tissue may invade gap
b. Flap positioned at bone crest leaving the gap exposed Easier Plaque and food may get trapped in void
if clot is not retained

2. BONE GRAFT PLACED INTO THE DEFECT WITH OR WITHOUT GROWTH FACTORS
a. Flap placed over the defect Covers defect This may require flap advancement
Increased morbidity (edema and ecchymosis)
Soft tissue may invade bone graft
b. Flap positioned at bone crest, leaving the gap exposed Easier Plaque and food may get trapped in void
if clot is not retained

3. BARRIER PLACED OVER DEFECT

a. Flap advancement is usually necessary to attain primary closure Covers barrier Increased morbidity (edema and ecchymosis)
b. No flap advancement and use of nonresorbable Easier Nonresorbable barrier-exposure/infection
or resorbable barrier or connective tissue graft Resorbable barrier-rapid dissolution in mouth

4. BARRIER PLACED OVER BONE GRAFT

a. Flap advancement is usually necessary to attain primary closure Covers barrier Increased morbidity (edema and ecchymosis)
Nonresorbable barrier-exposure/infection
b. No flap advancement and use of nonresorbable or resorbable barrier Easier Nonresorbable barrier-exposure/infection
or connective tissue graft Resorbable barrier-rapid dissolution in mouth

5. TEMPORIZATION OF IMPLANT AND ABUTMENT Supports Additional work at time of surgery

soft tissue Sufficient primary stability required
Reasonable restorative position required

B. NO FLAP ELEVATION (FLAPLESS IMPLANT INSERTION) ADVANTAGE DISADVANTAGE

1. THE GAP IS LEFT OPEN WITH NO ADDITIONAL THERAPY Easier Plaque and food may get trapped in void
if clot is not retained

2. BONE IS PLACED WITHIN THE GAP Bone particles may be displaced

3. TEMPORIZATION OF IMPLANT AND ABUTMENT WITH EITHER OF THE ABOVE Supports soft tissue Additional work at time of surgery

an implant encroaches upon the buccal plate of bone, it will of the time.55 When necessary, place the implant in the first
induce resorption (Figure 4).54 This is particularly true in the bicuspid alveolus parallel to the canine, not parallel to the
esthetic zone. In this regard, when large implants are placed second premolar. Minor parallelism discrepancies can be
in molar sites and engage the buccal or lingual plate of bone,
they may induce some bone loss.
Figure 4. Intraoral
Maxillary Canine Tilt occlusal view of an
immediately placed
Always check the radiograph to assess angulations of implant at site No. 5. It
adjacent teeth and possible dilacerations of roots before is positioned to remain
distant from the labial
drilling an osteotomy. This is particularly critical when placing plate of bone. Primary
a maxillary first premolar implant, because maxillary canines stability is achieved
apically and
are often angled 11 distally and the root curves distally 32% interproximally.

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 Continuing Education

Immediate Dental Implant Placement: Technique, Part 1

reconciled at the abutment level by utilizing angulated a
abutments (Figures 5a to 5d).

Flap Versus Flapless Implant Insertion

A clinician has multiple therapeutic options regarding
immediate implant placement: flap versus flapless surgery,
bone grafting, and barrier utilization (Table 4).56 Comments
in Table 4 relate to circumstances where the bony plate is
undamaged and does not need a regenerative procedure to Figure 5a. Radiograph after
restore bone contour. If implant insertion is performed extraction of the maxillary left first
premolar (No. 12). Note the distal
flaplessly, a cover screw or short healing abutment can be tilt of the adjacent canine tooth root.
placed and the implant can be submerged, but this usually
entails flap advancement if only one tooth was removed. b
Sometimes submergence is desirable if the implant is
placed under a provisional partial or full denture, or if the
implant was a spinner, or if it was inserted in soft quality
bone and it is questionable how well initial stability would
withstand occlusal stresses. Alternately, a healing, interim,
or definitive abutment can be placed with or without a Figure 5b. Radiograph of
immediately placed post
provisional crown that is not in occlusal function. Recent placement of the implant into the
data indicate that when an immediate implant was placed extraction socket of No. 12. The
implant has been placed to avoid
flaplessly in the esthetic zone in conjunction with an encroachment on the canine root.
abutment, a provisional crown, and a bone graft placed in
the buccal gap that extended coronally from the crest of the c
bone to the gingival margin (referred to as dual-zone
therapy), the amount of bone loss and recession were
minimal.57,58
Figure 5c. Clinical view of implant
CONCLUDING REMARKS level transfer coping demonstrating
the need to use an angled
Placement of immediate implants is a predictable abutment to correct implant
trajectory at site No. 12.
procedure and attention to detail is essential to ensure
success when placing these implants. Type 1 and usually d
Type 2 sockets are candidates for immediate implant
placement and require preservation of adjacent tissues
around the implant. Part 1 of this article has discussed
indications/contraindications for immediate implant place- Figure 5d. Clinical view of an
ment, healing phase and bone loss after extraction, and angulated abutment torqued to
place at site No. 12. A line of draw
practical suggestions for immediate implant placement. Part has been created that enables the
2 will provide practical information for positioning immediate restoration to be seated.

implants in different sections of the mouth.

6

Immediate Dental Implant Placement: Technique, Part 1
REFERENCES
1. Schulte W, Kleineikenscheidt H, Lindner K, et al. The
Tbingen immediate implant in clinical studies [in
German]. Dtsch Zahnarztl Z. 1978;33:348-359.
2. Lang NP, Pun L, Lau KY, et al. A systematic review on
survival and success rates of implants placed
immediately into fresh extraction sockets after at least
1 year. Clin Oral Implants Res. 2012;23(suppl 5):39-66.
3. Ortega-Martnez J, Prez-Pascual T, Mareque-Bueno S,
et al. Immediate implants following tooth extraction. A
systematic review. Med Oral Patol Oral Cir Bucal.
2012;17:e251-e261.
4. Evian CI, Waasdorp JA. Evaluating extraction sockets in
the esthetic zone for immediate implant placement.
Compend Contin Educ Dent. 2011;32:e58-e65.
5. Kois JC. Predictable single-tooth peri-implant esthetics:
five diagnostic keys. Compend Contin Educ Dent.
2004;25:895-907.
6. Waasdorp JA, Evian CI, Mandracchia M. Immediate
placement of implants into infected sites: a systematic
review of the literature. J Periodontol. 2010;81:801-808.
7. Crespi R, Cappar P, Gherlone E. Immediate loading of
dental implants placed in periodontally infected and non-
infected sites: a 4-year follow-up clinical study. J
Periodontol. 2010;81:1140-1146.
8. Crespi R, Cappar P, Gherlone E. Fresh-socket implants
in periapical infected sites in humans. J Periodontol.
2010;81:378-383.
9. Tan WL, Wong TL, Wong MC, et al. A systematic review
of post-extractional alveolar hard and soft tissue
dimensional changes in humans. Clin Oral Implants Res.
2012;23(suppl 5):1-21.
10. Vera C, De Kok IJ, Chen W, et al. Evaluation of post-
implant buccal bone resorption using cone beam
computed tomography: a clinical pilot study. Int J Oral
Maxillofac Implants. 2012;27:1249-1257.
11. Degidi M, Daprile G, Nardi D, et al. Buccal bone plate in
immediately placed and restored implant with Bio-Oss
collagen graft: a 1-year follow-up study. Clin Oral
Implants Res. 2012 Aug 13. [Epub ahead of print]
12. Brownfield LA, Weltman RL. Ridge preservation with or
without an osteoinductive allograft: a clinical,
radiographic, micro-computed tomography, and histologic
study evaluating dimensional changes and new bone
formation of the alveolar ridge. J Periodontol.
2012;83:581-589.
13. Job S, Bhat V, Naidu EM. In vivo evaluation of crestal
bone heights following implant placement with flapless
and with-flap techniques in sites of immediately loaded
implants. Indian J Dent Res. 2008;19:320-325.
7
Continuing Education
14. Fickl S, Zuhr O, Wachtel H, et al. Tissue alterations after
tooth extraction with and without surgical trauma: a
volumetric study in the beagle dog. J Clin Periodontol.
2008;35:356-363.
15. Barros RRM, Novaes AB Jr, Papalexiou V. Buccal bone
remodeling after immediate implantation with a flap or
flapless approach: a pilot study in dogs. Titanium.
2009;1:45-51.
16. Blanco J, Nuez V, Aracil L, et al. Ridge alterations following
immediate implant placement in the dog: flap versus flapless
surgery. J Clin Periodontol. 2008;35:640-648.
17. Mal P, Nobre M. Flap vs. flapless surgical techniques at
immediate implant function in predominantly soft bone for
rehabilitation of partial edentulism: a prospective cohort
study with follow-up of 1 year. Eur J Oral Implantol.
2008;1:293-304.
18. De Bruyn H, Atashkadeh M, Cosyn J, et al. Clinical
outcome and bone preservation of single TiUnite
implants installed with flapless or flap surgery. Clin
Implant Dent Relat Res. 2011;13:175-183.
19. Caneva M, Botticelli D, Salata LA, et al. Flap vs. flapless
surgical approach at immediate implants: a
histomorphometric study in dogs. Clin Oral Implants Res.
2010;21:1314-1319.
20. Arajo MG, Lindhe J. Ridge alterations following tooth
extraction with and without flap elevation: an
experimental study in the dog. Clin Oral Implants Res.
2009;20:545-549.
21. Becker W, Wikesj UM, Sennerby L, et al. Histologic eval-
uation of implants following flapless and flapped surgery: a
study in canines. J Periodontol. 2006;77:1717-1722.
22. Ferrus J, Cecchinato D, Pjetursson EB, et al. Factors
influencing ridge alterations following immediate implant
placement into extraction sockets. Clin Oral Implants
Res. 2010;21:22-29.
23. Arajo MG, Wennstrm JL, Lindhe J. Modeling of the
buccal and lingual bone walls of fresh extraction sites
following implant installation. Clin Oral Implants Res.
2006;17:606-614.
24. Vignoletti F, de Sanctis M, Berglundh T, et al. Early
healing of implants placed into fresh extraction sockets:
an experimental study in the beagle dog. II: ridge
alterations. J Clin Periodontol. 2009;36:688-697.
25. De Santis E, Botticelli D, Pantani F, et al. Bone
regeneration at implants placed into extraction sockets of
maxillary incisors in dogs. Clin Oral Implants Res.
2011;22:430-437.
26. Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations
following immediate implant placement in extraction sites.
J Clin Periodontol. 2004;31:820-828.

Immediate Dental Implant Placement: Technique, Part 1
27. Sanz M, Cecchinato D, Ferrus J, et al. A prospective,
randomized-controlled clinical trial to evaluate bone
preservation using implants with different geometry
placed into extraction sockets in the maxilla. Clin Oral
Implants Res. 2010;21:13-21.
28. Arajo MG, Lindhe J. Dimensional ridge alterations
following tooth extraction. An experimental study in the
dog. J Clin Periodontol. 2005;32:212-218.
29. Caneva M, Salata LA, de Souza SS, et al. Hard tissue
formation adjacent to implants of various size and
configuration immediately placed into extraction sockets:
an experimental study in dogs. Clin Oral Implants Res.
2010;21:885-890.
30. Paolantonio M, Dolci M, Scarano A, et al. Immediate
implantation in fresh extraction sockets. A controlled
clinical and histological study in man. J Periodontol.
2001;72:1560-1571.
31. Chen ST, Wilson TG Jr, Hmmerle CH. Immediate or
early placement of implants following tooth extraction:
review of biologic basis, clinical procedures, and
outcomes. Int J Oral Maxillofac Implants.
2004;19(suppl):12-25.
32. Spray JR, Black CG, Morris HF, et al. The influence of
bone thickness on facial marginal bone response: stage
1 placement through stage 2 uncovering. Ann
Periodontol. 2000;5:119-128.
33. Juodzbalys G, Wang HL. Soft and hard tissue
assessment of immediate implant placement: a case
series. Clin Oral Implants Res. 2007;18:237-243.
34. Favero G, Botticelli D, Favero G, et al. Alveolar bony crest
preservation at implants installed immediately after tooth
extraction: an experimental study in the dog. Clin Oral
Implants Res. 2013;24:7-12.
35. Evans CD, Chen ST. Esthetic outcomes of immediate
implant placements. Clin Oral Implants Res. 2008;19:73-80.
36. Kim CS, Choi SH, Chai JK, et al. Periodontal repair in
surgically created intrabony defects in dogs: influence of
the number of bone walls on healing response. J
Periodontol. 2004;75:229-235.
37. Favero G, Lang NP, Favero G, et al. Role of teeth
adjacent to implants installed immediately into extraction
sockets: an experimental study in the dog. Clin Oral
Implants Res. 2012;23:402-408.
38. Collaert B, De Bruyn H. Immediate functional loading of
TiOblast dental implants in full-arch edentulous maxillae:
a 3-year prospective study. Clin Oral Implants Res.
2008;19:1254-1260.
39. Norton MR. A short-term clinical evaluation of
immediately restored maxillary TiOblast single-tooth
implants. Int J Oral Maxillofac Implants. 2004;19:274-281.
8
Continuing Education
40. Ostman PO, Wennerberg A, Albrektsson T. Immediate
occlusal loading of NanoTite PREVAIL implants: a
prospective 1-year clinical and radiographic study. Clin
Implant Dent Relat Res. 2010;12:39-47.
41. Galli F, Capelli M, Zuffetti F, et al. Immediate non-occlusal
vs. early loading of dental implants in partially edentulous
patients: a multicentre randomized clinical trial. Peri-
implant bone and soft-tissue levels. Clin Oral Implants
Res. 2008;19:546-552.
42. Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation
of alveolar bone in extraction sockets using bioabsorbable
membranes. J Periodontol. 1998;69:1044-1049.
43. Lekovic V, Kenney EB, Weinlaender M, et al. A bone
regenerative approach to alveolar ridge maintenance
following tooth extraction. Report of 10 cases. J
Periodontol. 1997;68:563-570.
44. Camargo PM, Lekovic V, Weinlaender M, et al. Influence
of bioactive glass on changes in alveolar process
dimensions after exodontia. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2000;90:581-586.
45. Crespi R, Cappar P, Gherlone E, et al. Immediate
occlusal loading of implants placed in fresh sockets after
tooth extraction. Int J Oral Maxillofac Implants.
2007;22:955-962.
46. Liares A, Mardas N, Dard M, et al. Effect of immediate
or delayed loading following immediate placement of
implants with a modified surface. Clin Oral Implants Res.
2011;22:38-46.
47. Younis L, Taher A, Abu-Hassan MI, et al. Evaluation of bone
healing following immediate and delayed dental implant
placement. J Contemp Dent Pract. 2009;10:35-42.
48. Greenstein G, Caton J, Polson A. Trisection of maxillary
molars: a clinical technique. Compend Contin Educ Dent.
1984;5:624-632.
49. Botticelli D, Berglundh T, Lindhe J. Resolution of bone
defects of varying dimension and configuration in the
marginal portion of the peri-implant bone. An
experimental study in the dog. J Clin Periodontol.
2004;31:309-317.
50. Chen ST, Darby IB, Reynolds EC. A prospective clinical
study of non-submerged immediate implants: clinical
outcomes and esthetic results. Clin Oral Implants Res.
2007;18:552-562.
51. Arajo MG, Lindhe J. Dimensional ridge alterations
following tooth extraction. An experimental study in the
dog. J Clin Periodontol. 2005;32:212-218.
52. Atieh MA, Ibrahim HM, Atieh AH. Platform switching for
marginal bone preservation around dental implants: a
systematic review and meta-analysis. J Periodontol.
2010;81:1350-1366.
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Immediate Dental Implant Placement: Technique, Part 1

53. Sorni-Brker M, Pearrocha-Diago M, Pearrocha-Diago
M. Factors that influence the position of the peri-implant
soft tissues: a review. Med Oral Patol Oral Cir Bucal.
2009;14:e475-e479.
54. Vela X, Mndez V, Rodrguez X, et al. Crestal bone
changes on platform-switched implants and adjacent teeth
when the tooth-implant distance is less than 1.5 mm. Int J
Periodontics Restorative Dent. 2012;32:149-155.
55. Misch CE. Root form surgery in the edentulous
mandible: stage I implant insertion. In: Misch CE, ed.
Contemporary Implant Dentistry. 2nd ed. St Louis, MO:
Mosby; 1999:347-370.
56. Greenstein G, Cavallaro J. Managing the buccal gap and
plate of bone: immediate dental implant placement. Dent
Today. 2013;32:70-79.
57. Tarnow D. Immediate vs. delayed socket placement: what
we know, what we think we know and what we dont
know. Presented at: American Academy of
Periodontology; November 14, 2011; Miami Beach, FL.
58. Chu SJ, Salama MA, Salama H, et al. The dual-zone
therapeutic concept of managing immediate implant
placement and provisional restoration in anterior
extraction sockets. Compend Contin Educ Dent.
2012;33:524-534.

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 Continuing Education

Immediate Dental Implant Placement: Technique, Part 1

POST EXAMINATION INFORMATION POST EXAMINATION QUESTIONS
To receive continuing education credit for participation in 1. According to Evian et al, Type I sockets require
this educational activity you must complete the program which of the following?
post examination and receive a score of 70% or better. a. Soft-tissue augmentation.
b. Hard-tissue augmentation.
Traditional Completion Option:
c. Soft- and hard-tissue preservation.
You may fax or mail your answers with payment to Dentistry
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Today (see Traditional Completion Information on following
augmentation.
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and Evaluation forms. Your exam will be graded within 72
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exam (70% or higher), a letter of completion will be mailed b. Type II.
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have not previously purchased the program, select it from a. 1.24 mm.
the Online Courses listing and complete the online b. 3.79 mm.
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Select the Take Exam link, complete all the program thinnest plate of bone?
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Online users may log in to dentalcetoday.com any time in If pathosis exists, then all granulomatous tissue
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 Continuing Education

Immediate Dental Implant Placement: Technique, Part 1

6. After tooth extraction, it is advisable to place the 9. As a general rule, platforms of immediate implants
immediate implant ______ into bone to attain primary should be placed ____ below the gingival margin.
stability if mechanical retention cannot be achieved a. 1 mm to 2 mm.
laterally.
b. 2 mm to 3 mm.
a. 1 to 3 mm.
c. 3 mm to 4 mm.
b. 3 to 5 mm.
d. 4 mm to 5 mm.
c. 5 to 7 mm.
d. 7 to 9 mm. 10. Maxillary canine teeth are often angled 11 distally.
The roots of maxillary canine teeth curve distally
7. Atieh et al reported that bone loss using platform 32% of the time.
switching after immediate implant placement was: a. The first statement is true, the second is false.
a. 0.05 mm to 0.99 mm. b. The first statement is false, the second is true.
b. 0.19 mm to 1.67 mm. c. Both statements are true.
c. 0.37 mm to 2.66 mm. d. Both statements are false.
d. 0.77 mm to 3.56 mm.

8. To avoid inducing recession in the maxillary esthetic

zone, it is preferable to do the following:
a. Avoid raising a buccal flap.
b. Extrude teeth.
c. Bone grafts should be placed to a crestal level.
d. Abutments should be removed and replaced several
times.

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 Continuing Education

Immediate Dental Implant Placement: Technique, Part 1

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