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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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 depart ment of periodontology at the College of Dental Med icine, 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 de layed 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
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 ob tained 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 de layed 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 1outlines 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
Effective Date: 1/1/2014 Expiration Date: 1/1/2017and soft tissue are available to support it: deciduous tooth, en do don tic failure, caries, deep probing depths due to periodontitis, vertical root fracture, and idiopathic root resorption. Con tra dictions to in serting immediate implants include inadequate height or width of bone, lack of soft tissue, ad verse location of nerves, proximity of ad jacent teeth, failure to achieve primary stability, and inability to attain a res toratively reasonable position, an gulation 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%).2,3Furthermore, im mediate implants
inserted into in fected 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 Socket—Six 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 horizontal10-12and 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 im plants.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 Placement—Many studies verified that immediate implant placement is accompanied by bone loss. This was corroborated in
dogs23-25and human clinical trials.26-27Commonly, there is
a reduction of vertical bone height and even a greater amount of horizontal bone loss.23,27The quantity of bone
resorption is larger on the buccal than the lingual side of an im plant, since the buccal plate is usually thinner.28,29The
degree of bone re duction is related to numerous factors
(Table 2).12-15,21,30-37
Immediate Implants Help Preserve Vertical Bone Height—Among patients who receive immediate implants, the amount of bone resorption during the first year after tooth extraction38-41 ap pears to be less than when teeth are
removed and no implants are placed.42-44This 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 Im plants),39
0.37 for Nano Tite Prevail (Biomet 3i),40and 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 im plants preserve bone. When the amount of osseous resorption that occurs after im mediate and delayed implant placement is compared, the data demonstrate that there are no differences in the quantity of bone lost.45-47
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.
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 as sessed on the day of implant insertion. Researchers did not consider that with delayed placement, bone loss occurred postextraction and before delayed insertion of an im plant. Therefore, it can be deduced that de layed placement resulted in a larger degree of bone loss than immediate implant insertion.
PRACTICAL SUGGESTIONS FOR IMMEDIATE
IMPLANT PLACEMENT
Atraumatic Tooth Removal Prior to Implant Insertion
Teeth need to be removed atraumatically to preserve the maximum amount of bone before immediate implant placement. The clinical situation will dictate if the tooth should be removed flaplessly (eg, if it is broken
subgingi-vally, clinician’s 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
Table 2. Factors Affecting Healing of the Bone and Adjacent Soft Tissue12-15,21,30-37
1. Flap elevation—Elevation of a flap and disturbance of blood supply can result in bone resorption.12-15
2. Size of horizontal bone gap—Gaps < 2 mm fill spontaneously without bone grafts or barriers, submerged or not submerged.30 3.Biomaterials—Graft materials included autogenous bone,
demineralized freeze-dried bone, and hydroxyapatite. All the techniques provided clinically acceptable defect resolution.31
4. Thickness of the buccal—Spray et al32noted 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. Buccolingual—The closer the implant is to the buccal plate, the greater the amount of bone resorption that occurs.21,34
6.Position of implants—Large 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 walls—The most favorable healing is in 3 walled defects,36which 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 surfaces—Textured implant surfaces provide greater surface area and improved levels of osseointegration compared to machined surfaces.
9. Role of adjacent teeth—Immediate implants placed in several adjacent sockets manifested more bone loss than implants which were inserted into a single socket adjacent to healthy teeth.37
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
Figure 1. Clinical view. The diamond bur is inserted into the periodontal ligament space of tooth No. 9. The diamond can be used mesially, distally, and palatally.
granulomatous tissue should be removed. At present, no studies have compared the healing response of bone around immediately placed implants with respect to bone fill related to the ab sence 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 osteotomy and placement of the im plant beyond the apex of the ex tracted tooth provide
primary im plant stability. It is advisable to place an implant a minimum of 3 to 5 mm into bone to attain primary stability if mechanical retention cannot be achieved laterally (Figures 2a and 2b). Occasionally, it is possible to place a tapered implant into an extraction socket with minimal to no osteotomy preparation, thereby relying on the threads’ engagement of the bone lateral to the socket walls.
Apicocoronal and Horizontal Placement of Immediate Dental Implants
In general, immediate implants should be placed one mm subcrestally as viewed from the midpoint of the labial plate to account for vertical bone height resorption (the implant often will be deeper interproximally).50,51 If the buccal or
lingual plates of bone are thin, the implants should be placed
more subcrestally, since there may be an increased amount of bone resorption. The amount of vertical bone loss can be decreased with platform switching. Atieh et al52reported that
bone loss with versus without platform switching after im mediate implant placement was re spectively, 0.05 mm to 0.99 mm versus 0.19 mm to 1.67 mm.
As a general rule, platforms of immediate implants should be placed 2 to 3 mm below the gingival margin
(Figures 3a to 3e).53 This may or may not correlate with
being 2 to 3 mm below the cemento-enamel junction (CEJ) of the adjacent teeth. Therefore, if recession occurred on the adjoining teeth, using the CEJ as a guide will provide a poor esthetic result.
Horizontally, implants should not touch the buccal plate of bone29 because there is a horizontal zone of influence, and if
Figure 2a.Radiograph of structurally unsound tooth No. 4. The tooth reaches the sinus.
Figure 2b. Radiograph demonstrating insertion of an implant with a diameter wider than the socket. In addition, aggressive apical threads engage the bone lateral to the socket walls.
a
b
Figure 3a. Radiograph of structurally unsound tooth No. 12 to be extracted.
Figure 3b.Clinical view of an immediately placed implant at site No. 12. The sink depth is approximately 4 mm apical to the free gingival margin.
Figure 3c.Radiographic view of implant at site No. 12.
Figure 3d.Intraoral clinical view of the definitive restoration at insertion at site No. 12. Figure 3e. Radiograph of the definitive restoration at site No. 12. a b c d e
an implant encroaches upon the buccal plate of bone, it will induce resorption (Figure 4).54This is particularly true in the
esthetic zone. In this regard, when large implants are placed in molar sites and engage the buccal or lingual plate of bone, they may induce some bone loss.
Maxillary Canine Tilt
Always check the radiograph to as sess angulations of adjacent teeth and possible dilacerations of roots before drilling an osteotomy. This is particularly critical when placing a maxillary first premolar implant, because maxillary ca nines are often angled 11° distally and the root curves distally 32%
of the time.55When necessary, place the im plant in the first
bicuspid alveolus parallel to the canine, not parallel to the second premolar. Minor parallelism discrepancies can be
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
Figure 4. Intraoral occlusal view of an immediately placed implant at site No. 5. It is positioned to remain distant from the labial plate of bone. Primary stability is achieved apically and interproximally.
reconciled at the abutment level by utilizing angulated abutments (Figures 5a to 5d).
Flap Versus Flapless Implant Insertion
A clinician has multiple therapeutic options regarding immediate im plant 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 re generative procedure to restore bone contour. If implant insertion is performed flaplessly, a cover screw or short healing abutment can be placed and the implant can be submerged, but this usually entails flap advancement if only one tooth was removed. Some times 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 provisional crown that is not in occlusal function. Recent data indicate that when an immediate implant was placed flaplessly in the esthetic zone in conjunction with an abutment, a provisional crown, and a bone graft placed in the buccal gap that extended coronally from the crest of the bone to the gingival margin (referred to as dual-zone therapy), the amount of bone loss and recession were minimal.57,58
CONCLUDING REMARKS
Placement of immediate implants is a predictable procedure and attention to detail is essential to ensure success when placing these implants. Type 1 and usually Type 2 sockets are candidates for immediate implant placement and require preservation of ad jacent tissues around the implant. Part 1 of this article has discussed in dications/contraindications for im mediate implant place-ment, healing phase and bone loss after extraction, and practical suggestions for immediate implant placement. Part 2 will pro vide practical information for positioning immediate implants in different sections of the mouth.
Figure 5a.Radiograph after extraction of the maxillary left first premolar (No. 12). Note the distal tilt of the adjacent canine tooth root.
a
Figure 5b. Radiograph of immediately placed post placement of the implant into the extraction socket of No. 12. The implant has been placed to avoid encroachment on the canine root.
b
Figure 5c. Clinical view of implant level transfer coping demonstrating the need to use an angled abutment to correct implant trajectory at site No. 12.
c
Figure 5d.Clinical view of an angulated abutment torqued to place at site No. 12. A line of draw has been created that enables the restoration to be seated.
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51. Araújo 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.
53. Sorni-Bröker M, Peñarrocha-Diago M, Peñar rocha-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, Méndez V, Rodríguez 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 don’t 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.
POST EXAMINATION INFORMATION
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POST EXAMINATION QUESTIONS
1. According to Evian et al, Type I sockets require which of the following?
a. Soft-tissue augmentation. b. Hard-tissue augmentation. c. Soft- and hard-tissue preservation. d. Soft-tissue preservation and hard-tissue
augmentation.
2. When the bony socket is intact in the coronal aspect but a fenestration is present apically, what is the socket classification according to Evian et al?
a. Type I. b. Type II. c. Type III. d. Type IV.
3. After an extraction, the average amount of vertical bone height that is lost if a flap is elevated is:
a. 1.24 mm. b. 3.79 mm. c. 2.46 mm. d. 3.56 mm.
4. When a tooth is extracted, which is usually the thinnest plate of bone?
a. Buccal. b. Lingual. c. Proximal.
d. Buccal and lingual are the same thickness.
5. After removing a tooth with a healthy periodontium it is not necessary to curette the periodontal ligament. If pathosis exists, then all granulomatous tissue should be removed.
a. The first statement is true, the second is false. b. The first statement is false, the second is true. c. Both statements are true.
6. After tooth extraction, it is advisable to place the immediate implant ______ into bone to attain primary stability if mechanical retention cannot be achieved laterally.
a. 1 to 3 mm. b. 3 to 5 mm. c. 5 to 7 mm. d. 7 to 9 mm.
7. Atieh et al reported that bone loss using platform switching after immediate implant placement was:
a. 0.05 mm to 0.99 mm. b. 0.19 mm to 1.67 mm. c. 0.37 mm to 2.66 mm. 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.
9. As a general rule, platforms of immediate implants should be placed ____ below the gingival margin.
a. 1 mm to 2 mm. b. 2 mm to 3 mm. c. 3 mm to 4 mm. d. 4 mm to 5 mm.
10. Maxillary canine teeth are often angled 11° distally. The roots of maxillary canine teeth curve distally 32% of the time.
a. The first statement is true, the second is false. b. The first statement is false, the second is true. c. Both statements are true.
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