I m m e d i a t e Im p l a n t

P lac e me n t
Surgical Techniques for Prevention and
Management of Complications

a, b
Mohanad Al-Sabbagh, DDS, MS *, Ahmad Kutkut, DDS, MS

KEYWORDS
 Immediate implant placement  Complications of immediate placement
 Techniques for immediate placement  Prevention of complications

KEY POINTS
 Clinical studies have reported successful outcome of immediate placement of dental im-
plants in fresh extraction sockets.
 Although immediate implant placement has advantages over delayed implant placement,
like any other procedure, it is associated with risks and complications.
 Case selection and evaluation of patient-related and implant-related factors are keys to
the success of immediate implant placement.
 A thorough discussion between practitioner and the patient is indispensable to discern
patient’s desires.

INTRODUCTION
Healing of Extraction Socket
Wound healing in an extraction socket is characterized by resorption of alveolar bone,
which may result in restorative complications.1,2 Healing of extraction sites when no
socket preservation techniques are used results in the resorption of an average of 1
to 2 mm of vertical alveolar bone height and an average of 4 to 5 mm of horizontal alve-
olar bone width. Most of this bone loss occurs during the first year after extraction, and
two thirds of this bone loss occurs within the first 3 months after extraction. Therefore,
preservation of alveolar bone immediately after tooth extraction has an important
impact on the functional and esthetic outcomes of subsequent prosthetic treatment.2
The purpose of preserving the extraction socket is to maintain the architecture of the

a
Division of Periodontology, Department of Oral Health Practice, College of Dentistry, Univer-
sity of Kentucky, 800 Rose Street, Lexington, KY 40536, USA; b Division of Restorative Dentistry,
Department of Oral Health Practice, College of Dentistry, University of Kentucky, 800 Rose
Street, Lexington, KY 40536, USA
* Corresponding author.
E-mail address: [email protected]

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74 Al-Sabbagh & Kutkut

alveolar bone, prevent soft tissue collapse, and minimize or eliminate the need for
future bone augmentation procedures.
Histologically, 4 important changes may occur during the 5 stages of normal healing
of the extraction site: External dimensional changes at the extraction socket, internal
dimensional changes within the extraction socket, dimensional changes in a damaged
extraction socket, and dimensional changes in the mucosa. The first stage of healing is
characterized by the formation of a blood clot as a coagulum of red and white blood
cells. The second stage is characterized by the formation of granulation tissue, which
replaces the clot over 4 to 5 days. The third stage is characterized by the formation of
connective tissue, which replaces granulation tissue over 14 to 16 days. The fourth
stage is characterized by the appearance of osteoid calcification, which begins at
the base and the periphery of the socket (early osteoid calcification is present within
7–10 days, and trabecular bone fills the socket by 6 weeks). The fifth stage is charac-
terized by complete epithelial closure of the socket after 24 to 35 days (bone filling oc-
curs between 5 and 10 weeks, and complete filling occurs by 16 weeks). Maximum
osteoblastic activity occurs within 4 to 6 weeks.3,4
External dimensional changes at the extraction socket consist of horizontal or buc-
colingual ridge reduction of approximately 5 to 7 mm (almost 50% of the initial ridge
width); this reduction occurs over a period of 6 to 12 months, although most of the
changes occur during the first 3 months. Reduction in the apicocoronal or vertical
height of 2.0 to 4.5 mm accompanies the horizontal change. Internal dimensional
changes within extraction sockets, consisting of a reduction of 3 to 4 mm in the vertical
height of the socket, or approximately 50% of the initial socket height, have been re-
ported after 6 months of healing. Most of this bone loss occurs during the first
3 months after tooth extraction. Dimensional changes in damaged extraction sockets
most likely consist of fibrous tissue that may occupy a portion of the socket, thereby
preventing normal healing and osseous regeneration.5
Elevating the flap after extraction may compromise the blood supply of the thin
buccal plate, which has little or no cancellous bone, resulting in partial or complete
resorption of the buccal plate. At the surgically treated tooth site (full-thickness flap
elevation) in dogs, the mean amount of bone loss is 1.0 mm buccal and 0.1 mm lingual.
Surface bone resorption has a more pronounced effect on the delicate buccal bone
than on the lingual bone.6

Fate of Buccal Bone

Buccal bone generally is thinner than lingual and palatal bone (Fig. 1). The crest of the
buccal bone is composed solely of bundle bone. Buccal dehiscence and fenestration

Fig. 1. (A) Thick buccal bone (arrow) of an extraction socket. (B) Thin buccal bone (arrow) of
an extraction socket.
 Immediate Implant Placement 75

of the buccal plate of socket are frequently present. There are 3 main sources of blood
supply to the alveolar bone around teeth: The periodontal ligament blood vessels, the
periosteal blood vessels, and the alveolar bone blood vessels. After tooth removal,
20% of the blood supply from periodontal ligament blood vessels is discontinued. If
a flap is elevated on the buccal side, the periosteal blood supply will be discontinued
for 4 to 6 days, until new anastomoses occur. The thin cortical bone buccal plate has
no endosteal blood vessels; therefore, complete resorption of the buccal plate may
occur if no socket preservation technique is used.7 Bone grafting is frequently used
to prevent collapse and to minimize resorption of the thin buccal plate.8 However,
no comparative clinical studies have evaluated the fate and stability of the buccal
bone over time with or without bone regeneration.
Immediate Implant Placement
Immediate implant placement is defined as the placement of an implant into the
extraction socket at the time of tooth extraction. Immediate loading is defined as
the placement of full occlusal or incisal loading on a dental implant restoration. Imme-
diate provisionalization is a clinical protocol for the placement of an interim prosthesis,
either with occlusal contact with the opposing dentition (ie, immediate occlusal
loading) or without such occlusal contact (ie, immediate nonocclusal loading) at the
same clinical visit during which the implant is placed. Delayed loading refers to
applying force on an implant at some point after initial placement; a prosthesis is
attached or secured after a conventional healing period (for the maxilla, 3–4 months;
for the mandible, 2–3 months). Early loading refers applying force on an implant after
initial placement; a prosthesis is attached to the implant(s) before the end of the con-
ventional healing period.
There is variation in the descriptive terminology used in the dental literature to
describe the timing of implant placement. In 2004, Hammerle and colleagues9 pub-
lished a consensus report containing a new classification system for the timing of
implant placement. This classification is based on the structural changes that occur
after extraction on and knowledge derived from clinical observations (Table 1).

OUTCOME AND ADVANTAGES OF IMMEDIATE IMPLANT PLACEMENT

Several retrospective, prospective, and randomized, controlled clinical studies have

evaluated the clinical outcome of immediate placement of an implant in an extraction
socket. Generally, clinical studies reported similar short-term and long-term survival
rates (1–7 years) for immediate and delayed implant placement.10–16 As reported by

Table 1
Timing of implant placement

Time After
Classification Terminology Extraction Clinical Findings
Type 1 Immediate implant placement Immediately Fresh extraction socket
Type 2 Early implant placement 4–6 wk Healed soft tissue
Type 3 Delayed implant placement 3–4 mo Healed soft tissue and
substantial bone healing
Type 4 Late implant placement >4 mo Completely healed bone

Adapted from Hammerle CH, Chen ST, Wilson TG Jr. Consensus statements and recommended clin-
ical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Im-
plants 2004;19(Suppl):26–8.
76 Al-Sabbagh & Kutkut

Lang and associates,17 the survival rate of immediate implants is 97.3% to 99%. The
effect of apical pathology on the survival of an implant immediately placed in an
extraction socket is debatable. Some studies have found that the survival rates for im-
plants placed immediately into infected sockets18 and those for implants placed in
noninfected socket or healed ridges are similar.19,20
Traditional guidelines have stressed the need for complete healing of the alveolar
bone before an implant is placed into a fresh extraction socket, a process that usu-
ally requires several months.21,22 This lengthy undisturbed healing period extends
the time of oral functional disability and substantial resorption of the alveolar ridge
may occur. Shanaman23 and Denissen and co-workers24 reported that the dimen-
sions of the alveolar ridge can be maintained after immediate implant placement,
whereas Werbitt and Goldberg25 reported that soft tissue preservation is optimal af-
ter immediate implant placement. Immediate implant placement may reduce the
number of operative interventions required and the treatment time.26 The ideal
orientation of the implant may be achieved.27 Preserving the architecture of the
hard and soft tissues at the extraction site may provide optimal restorative esthetics
(Table 2).23,28

GUIDELINES FOR IMMEDIATE IMPLANT PLACEMENT

Several indications suggest that immediate placement may be an appropriate pro-

cedure with good oral hygiene; the presence of a single failing tooth with good adja-
cent dentition; the presence of adequate and harmonious gingival architecture with
the surrounding dentition; adequate bone volume to accommodate an implant, with
minimum dimensions of 3.5  10 mm and without the need for bone grafting; no
dental trauma affecting the alveolar bone; osseous-level dental decay without puru-
lence; and endodontic failure without periapical infection, a residual nonrestorable
root, or root fracture (Fig. 2).29 On the other hand, the following are contraindica-
tions for immediate placement: Active infection, lack of bone beyond the apex, a
close relationship to anatomic vital structures (ie, mandibular canal, maxillary sinus,
nasal cavity), dental history of bruxism, parafunctional habits, lack of stable poste-
rior occlusion, perforation or loss of the labial bony plate after tooth removal, and
inability to achieve primary stability (Fig. 3).29 The most predictable method of suc-
cessful immediate implant placement are maintenance of the soft tissue architecture
with conservative tissue manipulation (ie, leaving the periosteum intact) to preserve
the blood supply, maintenance of the buccal plate, and firm implant stability with a
minimum torque value of 30 Ncm and an implant stability quotient of at least 60
(Box 1).
Micromovement
Micromovement caused by load peaks higher than friction hold is crucial. Micromove-
ment of the implant can grind and slowly smooth the bone surface, thereby reducing

Table 2
Advantages and disadvantages of immediate implant placement

Advantages Disadvantages
One surgical procedure Surgically demanding; complex procedure
Less treatment time Risk of marginal mucosal recession
Preservation of bone at extraction site Adjunct connective tissue graft
Reduction in cost Adjunct bone graft or guided bone regeneration
 Immediate Implant Placement 77

Fig. 2. Maxillary right incisor is nonrestorable. Site is suitable for immediate implant place-
ment. (A) Adequate bone past the root apex for primary stability and no evidence of radio-
graphic infection. (B) Thick gingival biotype with good adjacent dentition. (C) Intact thick
buccal plate of the extraction socket.

the interlock between bone and titanium and ultimately resulting in a loss of primary
stability. It is critical that there are no occlusal implant overloads during the early heal-
ing stage. Primary stability is important during the first days after implant installation.
The first weeks are a crucial period because primary stability can decrease to critical
levels before secondary stability develops. Any micromotion of more than 150 mm
causes fibrous encapsulation of the implant. Therefore, patients should be compliant
and should avoid high masticatory forces by eating only soft foods for at least for
6 weeks postoperatively.30,31

Fig. 3. Maxillary right central incisor has periodontal abscess. Site is not suitable for imme-
diate implant placement. (A) Clinical sign of active infection (pus). (B) Significant loss of the
extraction socket walls.
78 Al-Sabbagh & Kutkut

Box 1
Criteria for immediate implant placement

 Low-risk patient
 Low esthetic expectations
 Adequate quality and quantity of soft tissue
 Adequate quality and quantity of socket bone
 Absence of diffuse infection
 Healthy condition of adjacent teeth and supporting structures
 Primary stability

Horizontal Bone Defect (Jumping Distance)

A horizontal bone defect is defined as the longest distance in a perpendicular direction
from the implant surface to the socket wall.32 In 2003, Botticelli and associates33 intro-
duced the term jumping distance at implant sites with a horizontal defect dimension;
the jumping distance is the horizontal distance between the implant surface and the
surrounding bony wall of the socket.
The need for bone grafting and the use of a barrier after immediate implant place-
ment depend on the thickness of the labial plate and the size of the gap between
the implant and the adjacent alveolar bone. Although a thick labial plate is generally
resistant to resorption and grafting is unnecessary, bone grafting is frequently used
to prevent collapse and minimize resorption of the thin labial plate, regardless of the
gap size. Bone grafting aids in osteoconduction of osteogenic cells by preserving
space and promoting the formation of new bone (the scaffold effect).8 Human and an-
imal studies have shown that, in implant sites with an horizontal defect dimension of
2 mm or less, spontaneous bone regeneration and osseointegration with adequate
bone-to-implant contact can occur; however, if the horizontal defect dimension is
larger than 2 mm, the use of a barrier membrane with or without membrane-
supporting bone grafting material is warranted for achieving adequate bone-to-
implant contact and proper osseointegration.32,34,35 Botticelli and colleagues36
reported that no bone grafting is needed even if the jumping distance is greater
than 2 mm. In a case report study, Tarnow and colleagues37 concluded that no
bone graft, membrane, or primary closure is necessary for filling the jumping distance,
provided that the buccal plate is intact after extraction (Fig. 4).
Submerged or Transmucosal Implant Placement
The submerged placement protocol was introduced by Brånemark and colleagues.38
With this approach, the implant is sealed from the outer environment by the mucosa,
and this sealing may decrease the chances of implant contamination.39 However,
several publications of clinical trials using the transmucosal approach for immediate
implant placement reported successful outcome.11,12,40
Tapered or Parallel Side Implant Design
Tapered design implants were used in several clinical studies, and were reported with
high success and survival rates in the immediate implant protocol. Because tapered
implants are narrow apically and wide coronally, they have the advantage of filling
the gap between the implant body and the socket wall at the crest level. It also im-
proves the implant’s primary stability, avoiding buccal wall engagement in the anterior
 Immediate Implant Placement 79

Fig. 4. Horizontal defect dimension (jumping distance). (A) Fresh extraction socket with
intact walls. (B) Longest distance in a perpendicular direction from the implant surface to
the socket wall (arrows). (C) The jumping distance was grafted with bone particulate.

region, and reducing the need for jumping distance augmentation.41–43 McAllister and
associates41 reported safe and effective application after using variable thread
tapered implants. Although the difference was not significant, Sanz and colleagues43
reported less vertical and horizontal space using tapered implants than of cylindrical
implants after immediate implant placements. However, Lang and colleagues40 found
in a clinical trial that both cylindrical and tapered implants have shown similar short-
term outcomes with regard to wound healing and primary stability. Bone augmenta-
tion at the time of implant placement was required for both designs in transmucosal
placement approach.

Rough Surface
Increased surface roughness of an implant can help to improve primary stability.44 In
a clinical study involving 1925 immediate implants placed from 1988 to 2004,
Wagenberg and Froum45 reported a higher success rate for immediate implants
with rough surface than for immediate implants with machined surfaces.

Implant Design
The effect of the design of the implant collar or neck placed immediately after the tooth
extraction on the peri-implant soft and hard tissues has been explored in several
experimental studies.46–48 They reported that implants with roughened and micro-
threaded neck would cause less resorption of the crestal bone than implants with
roughened and not microthreaded neck. These studies are in agreement with 1 clinical
study involving delayed implant placement, which showed less marginal bone resorp-
tion around roughened and microthreaded neck than of machined neck.49 The use of
tapered platform-switched internal connection implants at the implant shoulder is
80 Al-Sabbagh & Kutkut

recommended for immediate implant placement, because these implants can allow
rapid rehabilitation with no adverse impact on implant survival.

GUIDELINES FOR PROVISIONALIZATION AND LOADING

The outcome of conventional implant loading is predictable in all clinical situations. It is

highly recommended in instances of poor primary implant stability, substantial bone
augmentation, small-diameter implants, and compromised host conditions.
Achieving primary stability is the key factor in the success of dental implants. Inser-
tion torque is among the methods used for clinical assessment of primary stability.
Insertion torque is the amount of torque required to place the dental implant into the
prepared osteotomy. With the introduction of newer dental implant systems, various
manufacturers have recommended different insertion torques: Low insertion torque,
moderate insertion torque, and high insertion torque (32–70 Ncm).50–52 Ottoni and col-
leagues51 compared immediate-loading implants (test group) that were restored
within 24 hours with a provisional crown and conventional-loading implants (control
group) after healing. A minimal insertion torque of 20 Ncm was standard for attaining
primary stability. The insertion torque was associated with the risk of implant failure for
the test group but not for the control group, in which 9 implants failed when the inser-
tion torque was 20 Ncm. The authors concluded that an initial insertion torque of
greater than 32 Ncm is necessary for immediate loading of a dental implant with pro-
visional restoration. Furthermore, adding 9.8 Ncm to the insertion torque decreases
the risk of implant failure by 20%.51 Atieh and colleagues52 investigated the influence
of insertion torque (32, 50, or 70 Ncm) and stress distribution on wide-diameter,
tapered oral implants placed immediately in extraction sockets of mandibular molars.
The authors found that the use of moderate insertion torque (32–50 Ncm) may reduce
the risk of implant failure in an extraction socket. Furthermore, they found that the
highest insertion torque of 70 Ncm introduced substantial stress and should be
avoided during immediate placement of an implant into a fresh extraction socket.
The use of higher insertion torque is linked to the introduction of stresses to the
bone. These stresses can directly affect the stability of the dental implant or hinder
the process of osseointegration by inducing micromovements, which can lead to fail-
ure. Cannizzaro and colleagues50 used the split-mouth design to investigate the effect
of medium insertion torque (25–35 Ncm) and high insertion torque (>80 Ncm) on single
implants with immediate loading placed without flaps into 50 patients.50 The patients
were observed for 6 months after initial loading. Osseointegration failed for 7 implants
placed with medium insertion torque (between 25 and 35 Ncm). On the other hand,
none of the implants placed with insertion torque higher than 35 Ncm failed. The au-
thors concluded that single implants with immediate loading should be placed with a
higher insertion torque so that early implant failure can be prevented.
Marginal bone loss around immediately loaded implants is comparable with that
associated with conventionally loaded implants. Ericsson and colleagues53 reported
crestal bone loss of 0.14 mm for immediate implant loading and 0.07 mm for conven-
tional implant loading. Recent systematic reviews reported that immediate loading is
associated with significantly less bone loss than conventional loading.54,55
Early implant failure can be minimized by avoiding lower insertion torque, especially
for an implant associated with immediate or early loading. Immediate and early loading
require high insertion torque (30–35 Ncm), an implant stability quotient of at least 60,
and minimal implant length (10 mm), as well as the absence of contraindications
such as parafunctional activities, large bone defects, and the need for sinus floor
elevation.
 Immediate Implant Placement 81

SURGICAL TECHNIQUES

Implant placement in a fresh extraction socket was first introduced by Schulte and as-
sociates.56 Since then, the immediate replacement of a missing tooth has been consid-
ered a time-effective approach.26,57 The buccal plate is usually more vulnerable to
resorption after extraction.2 Using an atraumatic extraction technique that results in
minimal trauma to hard and soft tissues is a key factor in immediate or delayed implant
placement.58 Generally, surgical elevation of a mucoperiosteal flap and tooth
sectioning are used when the clinician believes that excessive force would be neces-
sary to remove the tooth, when a substantial amount of the crown is missing or covered
by tissue, or when access to the root of a tooth is difficult, such as when a fragile crown
is present.59 Flapless and flap techniques for immediate implant placement have favor-
able hard tissue and soft tissue outcomes.60 Flapless implants are feasible and have
been shown to reduce postoperative discomfort for correctly selected patients.61,62
The concept of atraumatic extraction includes managing the soft and hard tissues
around the tooth. Atraumatic extraction may include placing an intrasulcular incision
360 around the tooth to cut the connective tissue fibers above the bone and to detach
the connective tissue fibers from the cementum.58 The interproximal contact surfaces
should be trimmed to facilitate the application of the periotome and the elevator and to
clear the path of tooth removal.58 The periotome is usually pushed into to the peri-
odontal ligament space with light mallet tapping along the crestal third of the inter-
proximal bone. This process should take 10 to 30 seconds, after which a forceps is
used with controlled force to luxate the tooth before extraction (Fig. 5).58 For

Fig. 5. Atraumatic extraction with integrity of alveolus maintained. (A) Periotome is pushed
into the periodontal ligament along the crestal third of the interproximal bone to luxate the
maxillary right lateral tooth. (B) Titan forceps is used to atraumatically extract the tooth. (C)
The tooth was extracted with the preservation of soft and bone tissues of the extraction
socket.
82 Al-Sabbagh & Kutkut

multirooted teeth, root sectioning and separation are advisable (Fig. 6).63 A drilling
depth of 4 to 6 mm is required for sectioning the upper first and second molars,
whereas a drilling depth of 3 to 4 mm is required for the lower first and second molars.
A long fine bur is recommended for sectioning the roots.64 All granulation tissue should
be removed from the extraction socket.
The osteotomy for an immediate placement of anterior implant could be initiated
more palatally (Fig. 7), whereas for premolars and molars the osteotomy could be
initiated toward the center of the socket. A Lindemann bur (Komet Dental, Lemgo,
Germany) or a small (number 2) round bur is recommended for creating the initial
hole in the extraction socket before the implant twist drills are used.
For the posterior region, the crown of the molar should be cut off horizontally. The
roots should be carefully separated, and the inter-radicular bone within the socket
should be maintained for use in osteotomy preparation. The Piezo procedure may
be used to assist in removal of the ankylosed roots. A round bur should be positioned
off center toward the lingual side of the inter-radicular septum. This positioning allows
for preparation of the implant placement site in a centrally located position but away
from the buccal bone plate. To compensate for natural bone resorption after tooth
extraction, the implant site must allow the implant to be seated 1 to 2 mm below
the margin of the intact buccal bony wall. If the residual jumping distance is more
than 2 mm wide, a bone graft should be used.65–68
Special attention should be paid to the restoratively driven 3-dimensional posi-
tioning of the implants.69 Immediate implant placement should always follow the
rule of restorative-driven 3-dimensional placement not only to provide functional
replacement of missing teeth, but also to satisfy the esthetic needs of the patient
particularly in the esthetic zone. More guidance on the proper 3-dimensional place-
ment of dental implants is provided by an article published in 2006 (Fig. 8).70
For adequate primary stability, immediate implants should be placed few millime-
ters beyond the socket39 or 3 to 5 mm past the apex.63 The diameter of the implant

Fig. 6. Root sectioning in the buccal lingual direction of mandibular molar.

 Immediate Implant Placement 83

Fig. 7. The initial hole for the preparation of implant osteotomy should be placed on the
conjunction of the middle and apical thirds of the lingual wall of the extraction socket of
maxillary anterior teeth.

should exceed the root diameter, and primary stability must be obtained with a pristine
apical and lateral socket wall.63
If the clinician believes that the existing socket precludes the attainment of primary
stability for an appropriately sized implant in an ideal restorative position, immediate
implant placement should be avoided, and guided bone regeneration and delayed
implant placement can be undertaken. The implant should not touch the buccal plate
of the socket wall in the maxillary anterior teeth, because such touching could cause
resorption of buccal plate and esthetic risk.71–73 The implant must be placed at least
1 mm subcrestally, especially if the buccal or lingual plates are thin,63 or 2 to 3 mm
below the gingival margin.74 The extraction and the placement of the implant should
be flapless, when possible,62 or can use a sulcular incision, 1 tooth mesial and 1 tooth
distal to the implant site, which could help to expose the buccal bone.61

Fig. 8. (A, B) Preoperative radiographic and clinical assessment of maxillary right lateral for
immediate implant placement. (C) Intraoperative assessment of apicocoronal placement of
immediate implant. (D) Intraoperative assessment of mesiodistal placement of immediate
implant. (E) Intraoperative assessment of buccolingual placement of immediate implant.
84 Al-Sabbagh & Kutkut

After immediate implant placement, the jumping distance or the horizontal gap be-
tween the implant and the buccal surface should be filled with bone fill if the gap is
larger than 2 mm.35,75 All types of bone fill are effective for closing the horizontal
gap (Tables 3 and 4).5

Provisional Options
The key elements in preserving ridge contour are protection and maintenance of the
bone graft during the healing phase of treatment, which can extend for several
months. A contoured healing abutment or provisional restoration provides these ele-
ments to the bone graft. The alternative to using a contoured healing abutment is the
fabrication of a screw-retained provisional restoration.
Screw-retained provisional restorations are more commonly fabricated of autopoly-
merizing acrylic resin in infra-occlusion than are cement-retained restorations. Excess
cement may compromise peri-implant tissues if it is not completely removed. The pro-
visional restorations should have subgingival contours that conform to support the soft
tissue emergence profile and help to protect the blood clot as well as any graft parti-
cles that may be placed.
In cases that do not involve immediate provisional restoration, a straight healing
abutment or a stock contoured healing abutment should be placed. A fixed partial
denture is more suitable than a removable partial denture in preventing any pressure
or movement at the surgical site. Moreover, the pontic can be modified to avoid con-
tact with the healing abutment.
Immediate provisional restoration can control displacement of the available soft tis-
sue around a single implant to create the desired soft tissue contour. Provisional res-
torations allow evaluation of esthetic parameters before treatment is completed and
provide comfort and psychological advantages for the patient. The cervical contour
of the temporary restoration will guide the scallop of the gingival margin and the height
of the interdental papillae.77,78

Loading of Single or Multiple Implants

Published studies have shown that the success rate for immediately loaded implants
is similar to that for delayed loaded implants.79,80 Patients who are partially or fully
edentulous may be predictably restored with a fixed prosthesis immediately upon
implant placement if certain criteria are met.
Immediate loading of implants has biologic advantages: It increases bone density
around the implant, increases bone remodeling around the implant, and provides
bone-to-implant contact similar that achieved by delayed loading of implants, as
demonstrated histologically. Immediately loaded implants exhibited bone-to-implant
contact of 92.9%.81,82
Several factors must be considered for successful immediate loading. Creating
cross-arch stabilization by splinting multiple implants together, placing implants in
bone of higher density, using tapered implants to provide a wedging effect, placing
long wide-diameter implants with a minimum height of 10 mm and a minimum width
of 4 mm, and using a rough surface implant increases the surface area for better
osseointegration.83 A major disadvantage of immediate loading of implants is that
no second-stage procedure is performed, so there is no chance to modify soft tissue.
As long as the factors for successful implants (initial stability, immobilization, and pa-
tient compliance) are met and the principle of no movement greater than 150 mm is
fulfilled, even in bone with poor quality, and even in periodontally involved cases, suc-
cess can be achieved with immediate loading.
 Immediate Implant Placement 85

Table 3
Surgical exploration for immediate implant placement

Consideration Details
Difficulty of extraction a. Atraumatic (careful luxation, possible use of a periosteotome
for anterior teeth, consider flapless procedure)
b. Difficult
Anatomy of the socket a. Buccal cortical wall thickness
b. Buccal wall integrity: Fenestration or dehiscence
The most important aspects of an extraction site in determining its
suitability for immediate implantation are:
The number of remaining walls
The preexisting amount of attachment loss
The position and condition of the arch
This is one of the most important parts of decision making
because it determines the need for more advanced
procedures, such as GBR or CTG
Availability of bone a. Ample 4 mm: Suitable for immediate implant placement
past the apex of the b. Limited: Primary stability may not be achieved in certain sites
root
Primary stability a. Absence of axial or lateral mobility with physical resistance to
rotation
b. Place depth gauge and compare depth with proposed length
and width of implant
c. If inadequate primary stability, immediate implant placement
is not recommended
Implant positioning Restoration-driven implant positioning should be achieved in 3
dimensions for optimal esthetic treatment outcome
a. Buccolingual
b. Mesiodistal
c. Apicocoronal
d. Angulation
HDD a. HDD < 2 mm: Augmentation not required, defect will heal
spontaneously
b. HDD > 2 mm: Will not heal predictably; augmentation required
Adjunct therapy a. Intact thick buccal bone with thick gingival biotype: Immediate
implant placement, consider flapless procedure
b. Intact thick buccal bone, thin scalloped biotype: Immediate
implant placement, consider CTG
c. Intact thin buccal bone and thick scalloped biotype: Immediate
implant placement with flapless procedure and grafting of
facial jumping distance
d. Intact thin buccal bone and thin scalloped biotype: Possible
immediate implant placement in low-risk patients with flapless
procedure and grafting of facial jumping distance in addition
to staged CTG
c. Small defect in buccal bone, but implant can be placed with
stability: Possible immediate implant placement with GBR with
or without staged CTG
d. Major defect in buccal bone, implant will not be placed in
optimal position: Consider delayed implant placement

Abbreviations: CTG, connective tissue graft; GBR, guided bone regeneration; HDD, horizontal
defect dimension.
86 Al-Sabbagh & Kutkut

Table 4
Recommendations for osteotomy preparation for immediate implant placement

Teeth Initial Osteotomy Preparation Attainment of Primary Stability

Maxillary Initial hole should be placed on the Apical: Provide the prime stability by
anterior conjunction of the middle and engaging 3–4 mm of native bone
teeth apical thirds of the lingual wall of past the apex of the socket.
the extraction socket. Engagement Horizontal: Provide additional
of buccal wall of the extraction stability by engaging the palatal
socket with implant body should be wall of the socket with the implant
avoided. body.
Maxillary Attempt to place the initial hole in Apical: Provide additional stability by
premolar the middle but slightly toward the engaging 3–4 mm of native bone
teeth lingual of the socket. If a furcation past the apex of socket, if available.
septum exists, slightly remove the Horizontal: Provide the prime
inter-radicular bone crest until stability by engaging the mesial
enough septal bone width is and distal, and sometime the
attained. If initial drilling through palatal, wall of the socket with the
the septum is unsuccessful, the implant body.
initial hole can be placed in the
apical side of the palatal socket and
more toward the center. No
engagement of the buccal bone by
the body of the implant.
Maxillary Immediate placement is generally is Apical: Provide the prime stability by
molar not recommended; however, if engaging 3–4 mm of native bone
teeth roots are divergent, osteotomy past the apex of socket.
preparation can be initiated by Horizontal: May provide primary
drilling into the center of the inter- stability in case of neumatized
radicular bone. If a narrow septum maxillary sinus by engaging the
exists, slightly remove the inter- palatal, mesial, and distal wall of
radicular bone crest until enough the socket with the wide implant
septal bone width is attained. It is body.
not recommend using the palatal
root as a site of immediate implant
placement because restorative-
driven 3-dimensional placement of
the implant may not be achieved.
The implant neck may engage the
mesial, distal, and palatal plate of
the extraction socket.
Mandibular Initial osteotomy preparation should Apical: Provide the prime stability by
anterior be straight through the middle of engaging 3–4 mm of native bone
teeth the socket. past the apex of the socket.
Horizontal: No engagement of
buccal, lingual, mesial, or distal
walls of the socket by the narrow
implant body is recommended.
Mandibular Initial osteotomy preparation should Apical: Provide additional stability by
premolar be straight through the middle of engaging 3–4 mm of native bone
teeth the socket. past the apex of socket, if available.
Horizontal: Provide the prime
stability by engaging the lingual,
mesial, and distal walls of the
socket with the implant body.
(continued on next page)
 Immediate Implant Placement 87

Table 4
(continued)

Teeth Initial Osteotomy Preparation Attainment of Primary Stability

Mandibular If roots are divergent, osteotomy Apical: Provide additional stability by
molars preparation can be initiated by the engagement of 3–4 mm of
drilling into the center of the native bone pass the apex of socket,
inter-radicular bone. If a narrow if available.
furcation septum exists, slightly Horizontal: Provide the prime stability
remove the inert-radicular bone by the engagement of the buccal,
crest until enough septal bone lingual, mesial and distal wall of
width is attained. If unsuccessful, socket by the wide implant body.
the initial hole can be placed in the
apical of mesial or distal root of the
socket and more toward the center,
opposing the lingual maxillary cusp.
It is not recommend using the
mesial or distal root as a site of
immediate implant placement
because restorative-driven
3-dimensional placement of the
implant may not be achieved.

Data from Refs.63,69,76

PREVENTION OF COMPLICATIONS ASSOCIATED WITH IMMEDIATE IMPLANT

PLACEMENT

Although immediate implant placement is associated with high success rates and
survival rates, complications can occur. The most common complications are poor
3-dimensional implant positioning, inadequate band of keratinized tissue, gingival reces-
sion, unacceptable esthetics, and implant failure because of surgical trauma, contami-
nation of the surgical field, premature loading, implant design, anatomic limitations
such as quality and quantity of bone, systemic factors, and unknown factors. Implant fail-
ure can be classified as early when osseointegration is not achieved or as late when
achieved osseointegration is lost after function begins. Early implant failure is caused
by inability to regenerate intimate bone-to-implant contact, resulting in impaired wound
healing after implant placement. Clinical indications of early implant failure are bone loss,
implant mobility, pain or other symptoms during function, and biological infection.84,85

Fenestration or Dehiscence
The complications of fenestration and dehiscence have been reported to occur after
immediate implant placement.39 The most commons area for fenestration during the
immediate implant placement are the maxillary anterior and premolar sockets. The
socket apex can be more facially oriented and is frequently misleading during the initi-
ation of the osteotomy preparation. A round bur positioned off center toward the
palatal side and along the alveolar ridge angulation reduces the chance of fenestration
of facial plate of the alveolar ridge. When these complications occur, spontaneous
bone regeneration may be possible; however, in some cases, delayed implant place-
ment is advisable.86,87 For managing fenestration or dehiscence, a resorbable or non-
resorbable membrane can be used with or without bone particulate from various
sources.5,88 However, bone augmentation techniques may lead to suboptimal
bone-to-implant contact and soft tissue esthetics, especially when achieving primary
closure of the surgical site is difficult (Fig. 9).89,90
88 Al-Sabbagh & Kutkut

Fig. 9. Fenestration of the buccal plate during immediate placement of implant in a fresh
extraction socket of maxillary premolar. (A) Penetration of apex of the implant through
the buccal bony plate (arrow). (B) Primary stability is achieved and bone graft particles
were placed. (C) Collagen membrane was placed on the bone particulates.

Bone Quality and Quantity

Implant failure rates are higher when the quality and quantity of bone at the implant site
are insufficient. Attaining primary stability is a prerequisite for successful osseointe-
gration, and accomplishing primary stability requires adequate bone quantity and den-
sity. An osteotome can be used to condense spongy trabecular bone, such as that
found in the posterior maxillary region. Packing of bone graft particulate and the simul-
taneous use of an osteotome may transform very spongy bone into more dense bone
(Fig. 10).

Gingival Biotype and Width of Keratinized Gingiva

The dental literature is inconclusive with regard to the effect of the presence or
absence of adequate keratinized gingiva around dental implants on the success or

Fig. 10. The use of osteotome with packing of bone graft material into an extraction socket
to expand the extraction socket and condense the spongy trabecular bone to increase the
primary stability.
 Immediate Implant Placement 89

failure of an implant. Recession can be avoided and the long-term stability of the
mucosal tissue around the implant can be ensured by the use of adjunct soft tissue
grafting. Authors of current article recommend following the adjunct soft tissue ther-
apy guidelines described in Table 3.
Surgical Trauma
Bone is viable and is sensitive to temperature. Overheating the bone during prepara-
tion of the implant osteotomy site can lead to necrosis of the bone tissue surrounding
the dental implant. Less surgical trauma is expected when clinicians are skillful and
experienced, and the clinician’s skill is an important factor in the successful outcome
of dental implants.
Overheating the bone should be avoided by using copious irrigation and periodic
replacement of twist drills to ensure sharpness. The implant manufacturer’s guidelines
for drilling speed should be followed, and low hand pressure is warranted during high-
speed drilling in dense bone.
Infection
Strict antiseptic protocol should be followed during surgical implant placement. Pre-
medication with broad-spectrum antibiotics is recommended. Thorough debridement
of contained infection in the extraction socket and excavation of all of the soft and
granulation tissues are necessary. In cases of active diffuse infection, delayed implant
placement is recommended.
Violation of Anatomic Structure
The availability of 3 to 5 mm of bone past the apex of the root is often necessary for
primary stability and is helpful for avoiding the violation of surrounding anatomic struc-
tures. The implementation of a vertical sinus lift with an osteotome and the placement
of a wide-neck implant decrease the likelihood of introducing an immediate implant
into the maxillary sinus cavity. Obtaining cross-sectional radiographic images for
locating the maxillary sinus, the nasal cavity, the inferior alveolar canal, and the lingual
undercut (submandibular fossa) is helpful for avoiding the violation of these anatomic
structure because it ensures at least 2 mm of clearance between the implant apex and
the surrounding structures.
Implant Stability
Primary stability and success of implants are more likely when implants are supported
by cortical bone. Bicortical anchorage is associated with some complications, but it
results in good primary stability and better distribution of loading forces than moncort-
ical anchorage.
Malpositioning of Implant
Restoration-driven implant position must be correct in 3 dimensions for optimal func-
tional and esthetic outcomes. Correction of integrated malpositioned implants is diffi-
cult and limited to prosthetic correction; otherwise, removal of the implant is
warranted. Buccolingual, mesiodistal, and apicocoronal angulation of an implant
immediately placed into an extraction socket is reviewed in an article published in
2006.70
Unesthetic Outcome
Certain esthetic complications are associated with immediate implant placement. For
example, tissue alterations leading to recession of the facial mucosa and papillae are
90 Al-Sabbagh & Kutkut

common after immediate placement. Indicators of risk of recession after immediate

placement include a thin tissue biotype, a facial malpositioning of the implant, and a
thin or damaged facial bone wall. A history of chronic periodontitis is an indicator of
risk of lack of survival of postextraction implants.91,92
In studies with observation period of 3 years or longer, approximately 20% of pa-
tients who underwent immediate implant placement and delayed restoration experi-
enced suboptimal aesthetic outcomes because of buccal soft tissue recession17
For optimal esthetic outcome and limiting of buccal mucosal recession, Tarnow and
colleagues37 recommend placing a bone graft and contoured healing abutment or
provisional restoration at the time of flapless implant placement in a postextraction
socket. For long-term stability of the mucosal tissue around the implant, the authors
of current article recommend following the guidelines of the use of an adjunct soft
and bone tissue grafting (see Table 3).

SUMMARY

Several clinical studies have reported successful outcome of immediate placement of

dental implants in fresh extraction sockets. Although immediate implant placement
has several advantages over delayed implant placement, it, like any other procedure,
is associated with risks and complications. Treatment protocols and guidelines should
be followed to prevent complications. Case selection and evaluation of patient-related
and implant-related factors are keys to the success of immediate implant placement.
A thorough discussion between practitioner and patient is indispensable to discern
patient’s desires. Practitioners need to consider these desires when planning immedi-
ate, early, or delayed implant placement.

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