Meijer and Raghoebar International Journal of Implant Dentistry

https://doi.org/10.1186/s40729-019-0201-7
(2020) 6:3
International Journal of
Implant Dentistry

RESEARCH Open Access

Immediate implant placement in molar

extraction sites: a 1-year prospective case
series pilot study
Henny J. A. Meijer1,2* and Gerry M. Raghoebar1

Abstract
Background: There is a growing tendency to place single tooth implants immediately after extracting a failing
tooth in the posterior region. The aim of this prospective case series pilot study was to evaluate immediate implant
placement in molar post-extraction sites during a 1-year follow-up period.
Materials and methods: Fifteen consecutive patients with a single failing molar in the maxilla or mandible, and
presenting enough bone to expect primary implant stability and an implant site free of infection, were included. The
implants, with a large thread depth and sharp thread edges, were placed in each patient according to a two-staged
surgical procedure. Three months later, a full contour screw-retained zirconia restoration with an angulated screw
channel abutment was provided. Clinical and radiographic examinations were performed 1 month and 12 months
after placing the restoration. In addition, the patients’ satisfaction with the restoration was scored after 12 months.
Results: Four out of 15 of the mobile implants had to be removed before the 1-year evaluation. The implant and
restoration survival rates were 73.3% at the 1-year evaluation (n = 15). The mean marginal bone loss, from loading to
the 12-month follow-up, was 0.17 mm (n = 11). The mean plaque, calculus, peri-implant mucosa, bleeding, and pocket
probing depth scores were low, depicting healthy peri-implant conditions. The patients were very satisfied.
Conclusion: It was demonstrated, within the limitations of this study, that immediate placement of regular diameter
implants in molar post-extraction sites in the maxilla and mandible resulted in a high implant failure rate during a 1-
year follow-up period.
Trial registration: Netherlands Trial Register, NL8117. Registered 24 October 2019 - Retrospectively registered, https://
www.trialregister.nl/trial/8117.
Keywords: Immediate implant placement, Posterior region, Extraction sites, Implant survival

Background surfaces and designs are facilitating the possibilities

Implant placement and loading protocols are changing [7, 8]. Despite systematic reviews pointing out that
[1]. There is a growing tendency to place single tooth there is a slightly higher risk of early implant loss
implants immediately after the extraction of a failing compared to delayed implant placement, immediate
tooth, especially in the maxillary aesthetic region, and implant placement in extraction sites is now pre-
preferably combined with immediate provisionalization sumed to be a reliable treatment option for single
[2–6]. This tendency is related to evolving society fac- tooth implants [1, 2, 9].
tors, including more demanding patients and a wish for It must be mentioned, however, that the majority of
direct treatment, whereupon innovations in implant studies on immediate implant placement are related to
the maxillary aesthetic region. Immediate implant place-
ment in the posterior region is studied much less, prob-
* Correspondence: [email protected]
1
Department of Oral and Maxillofacial Surgery, University Medical Center ably because those patients are less demanding and due
Groningen, PO Box 30.001, NL-9700 RB Groningen, The Netherlands to the different anatomical features of the extraction
2
Department of Implant Dentistry, University Medical Center Groningen, socket compared to that of the single-rooted teeth in
Groningen, The Netherlands

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Meijer and Raghoebar International Journal of Implant Dentistry (2020) 6:3 Page 2 of 7

the anterior maxilla [10, 11]. Nevertheless, two systematic The Medical Ethical Committee of the University
reviews mention that high survival rates have also been re- Medical Center Groningen considered this case series
ported for immediate implant placement in molar regions study was not subject to the Medical Research Involving
[12, 13]. Although it was suggested that wide diameter im- Human Subjects Act (Number M15.184100). The study
plants may have better results in the molar region than was registered at the Netherlands Trial Register (Num-
regular diameter implants [13, 14]), they also were associ- ber NL8117).
ated with a high failure rate [15]. Based on current pub-
lished controlled studies, there is still a lack of evidence Surgical and prosthetic procedures
for an optimal immediate implant placement protocol in The surgical and prosthetic treatments were performed
the molar region. Therefore, the aim of this prospective at the Department of Oral and Maxillofacial Surgery,
case series study was to evaluate immediate implant place- University Hospital Groningen. One oral surgeon, expe-
ment in molar post-extraction sites during a 1-year rienced in implant dentistry, executed the surgical treat-
follow-up period. ments and two experienced prosthodontists performed
the restorative procedures. All the laboratory procedures
Materials and methods were carried out in a single dental laboratory.
Patient enrolment
All patients referred to the Department of Oral and Surgical procedure
Maxillofacial Surgery (University of Groningen, Univer- The patients had a failing molar at the time of the inter-
sity Medical Hospital), from January 2016 to July 2017, vention (Fig. 1). Antibiotic prophylaxis (2 g amoxicillin
for single-tooth implant therapy in the maxillary and or, if allergic to penicillin, 600 mg clindamycin) was
mandibular posterior region were considered for inclu- given 1 h pre-operatively as was a 0.2% chlorhexidine
sion. The following inclusion criteria were applied: mouthwash (two times daily for 10 days) for oral disin-
fection. The first step of the surgical procedure, which
 One failing first or second molar in the maxilla or was performed under local anaesthesia, involved care-
mandible; fully detaching the periodontal ligament from the failing
 Sufficient bone volume, with an intact buccal and tooth by an incision in the sulcus. Periotomes were used
lingual wall, to insert a dental implant of at least 7 to extract the failing molar atraumatically. No mucoper-
mm in length; iosteal flap was raised. The interradicular bone of the al-
 Implant site is free from infection; veolus was prepared for the implant following the
 Adequate oral hygiene as expressed by the modified manufacturer’s protocol using a surgical template based
plaque index and the modified sulcus bleeding index on the ideal position of the prospective implant crown.
from Mombelli et al. [16]; The final twist drill was placed in the prepared socket.
 Sufficient mesio-distal, bucco-lingual, and interoc- The remaining space between the drill and bone walls
clusal space for the placement of an anatomic was augmented with a 1:1 mixture of autogenous bone,
restoration; harvested from the retromolar or tuberosity area using a
 The patient is capable of understanding and giving bonescraper (Bonescraper, Biomet 3i, Warsaw, Indiana,
informed consent. USA), and a bone substitute (Bio-Oss®, Geistlich Pharma
AG, Wolhusen, Switzerland). The drill was carefully re-
Patients were excluded from the experimental protocol moved and a regular diameter implant (NobelActive,
when at least one of the following exclusion criteria was Nobel Biocare AB, Goteborg, Sweden) was placed, ac-
met: cording to the manufacturers’ protocol. Regarding the
corono-apical position of the implant, the shoulder of
 Medical and general contra indications for the the implant was placed at a depth of 3 mm apical to the
surgical procedures; most apical aspect of the prospective clinical crown, with
 Presence of active and uncontrolled periodontal the help of a surgical template. The implant diameters
disease; were 4.3 mm, and the lengths varied from 8.5 mm to 10
 Bruxism; mm, depending on the available bone height at the im-
 An active smoker; plant site. The primary implant stability was > 45 Ncm,
 History of local radiotherapy to the head and neck measured with a manual torque wrench (NobelBiocare
region. AB). A cover screw (NobelBiocare AB) was placed and
the extraction socket closed with a mucosa graft, which
Patients fulfilling all the inclusion and none of the ex- was harvested from the tuberosity region. The wound
clusion criteria were informed verbally and in writing was closed with Ethilon 5-0 nylon sutures (Johnson &
about the study and signed the informed consent form. Johnson Gateway, Piscataway, NJ, USA). One week after
Meijer and Raghoebar International Journal of Implant Dentistry (2020) 6:3 Page 3 of 7

Fig. 1 Pre-operative panoramic radiograph of a failing molar in position 36

implant placement, a follow-up visit was scheduled for  The marginal bone level as measured on
suture removal and to review the healing process. After standardized intraoral radiographs;
3 months, the implant was uncovered and a healing  Assessment of plaque accumulation with the
abutment (NobelBiocare AB) was installed. modified Plaque Index [16];
 Assessment of bleeding tendency with the modified
Restorative procedure Sulcus Index [16];
An impression was made at implant level 2 weeks after  Assessment of peri-implant inflammation with the
the second stage of the surgery in order to fabricate a Gingival Index [17];
single crown. A definitive full-zirconia crown (yttria-sta-  Presence of calculus
bilized zirconium oxide) with an angulated screw chan-  Probing pocket depth: measured to the nearest
nel (NobelProcera FCZ Implant Crown, NobelBiocare millimetre using a manual periodontal probe
AB) was manufactured in the determined colour at a (Williams-Sulcus color-coded probe, Hu-Friedy,
centralized milling facility (NobelProcera Service Center, Chicago, IL, USA). The peri-implant sulcus was
Mahwah, NJ, USA) and then stained and glazed at a probed at four sites (at the mesial, distal, buccal and
dental laboratory to attain the final colour (Ceram Es- lingual/palatal side);
sence and Ceram Glaze Paste, Ivoclar Vivadent, Schaan,  Restoration survival;
Liechtenstein). The adapter and crown were assembled  Complications related to the restoration;
and screw-retained onto the implant with a torque of  Patients’ satisfaction. Patients were asked to
35Ncm. The screw access hole was sealed with a cotton complete a questionnaire 1 year after restoration
pellet and light-curing composite material (Fig. 2). The placement;
design of the occlusal surface allowed functional loading  Success rate: calculated from the criteria of success as
of restoration and implant. Immediately after placing the proposed by Albrektsson and colleagues in 1986 [18].
restoration, thorough oral hygiene instructions were
given to all the patients. Radiographs were taken and evaluated 1 month and
12 months after restoration placement using a parallel
Outcome measures technique, with an X-ray holder for periapical radio-
Clinical and radiographic evaluations were performed graphs. They were analysed using a specially designed
1 month and 1 year after restoration placement. The fol- computer software to perform linear measurements on
lowing criteria were considered: digital radiographs. The calibration was carried out in
the vertical plane of each radiograph by using the known
 Implant survival. The survival rate of the implant distance of the implant and the distance of several
was assessed 1 year after definitive restoration threads in order to ensure correct measurements [19].
placement. An implant was defined as a failure when Crestal bone changes were determined by measuring,
it was deemed necessary to remove the implant both mesially and distally, the distance from the implant
because of implant mobility as a consequence of loss reference point (the neck of the implant) to the margin
of osseointegration; level of the crestal bone. Bone loss was presented as the
Meijer and Raghoebar International Journal of Implant Dentistry (2020) 6:3 Page 4 of 7

Fig. 2 Intraoral radiograph of an immediately placed post-extractive dental implant with a full contour zirconia restoration after 1 year (same
patient as in Fig. 1)

worst distal and/or mesial bone level change between depicted in Table 1. All implant-supported restorations had
1 month and 12 months after restoration placement. natural antagonistic teeth. Four of the 15 patients treated
The patients’ recorded their satisfaction by means of had a mobile implant, which had to be removed (in two pa-
filling out a questionnaire 1 year after restoration place- tients 3 months after crown placement and in two patients
ment. The questionnaire included questions or state- 6 months after crown placement). Of the four failing im-
ments to be answered on a 5-point rating scale ranging plants, two were placed in the mandible and two in the
from “very dissatisfied” and “not in agreement” (score 1) maxilla, three were positioned in between two natural teeth
to “very satisfied” and “in agreement” (score 5). The ad- and one free-ending, and two of the original teeth in the
dressed topics were related to aesthetics and appearance, site of implant loss were lost because of crown fracture and
function (eating), sense (“feels like a natural tooth”), two because of root fracture. The remaining 11 patients
speech, and self-esteem. Furthermore, the patients were completed the 1-year evaluation. Implant and restoration
asked to mark their overall satisfaction with their dental survival were 73.3% at the 1-year evaluation. All the failed
situation at the 1-year evaluation on a 10-point rating implant patients were successfully treated again after a heal-
scale from 0 to 10, whereby 10 is the highest satisfaction ing period of 3 months (delayed placement).
score. The mean scores of the indices for plaque, calculus,
gingiva, and bleeding were very low, hence favourable
Statistical analysis (Table 2). There was no plaque and calculus at any of
One observer was responsible for the collection and ana-
lysis of all the data. The worst score of the clinical and Table 1 Baseline characteristics of the study group
radiographic parameters evaluated per implant was used Mean age in years (sd, minimum-maximum) 57 (6.6, 44–67)
in the data analysis. Data were presented as frequencies
Gender (number male/female) 6/9
without statistical testing.
Reason of failure (severe caries/crown 3/6/6
fracture/root fracture)
Results
Implant position (maxilla/mandible) 7/8
All 15 consecutive patients eligible to join the study on the
basis of the inclusion and exclusion criteria agreed to par- Implant position (in between teeth/no 11/4
tooth distally)
ticipate in this study. The patient characteristics are
Meijer and Raghoebar International Journal of Implant Dentistry (2020) 6:3 Page 5 of 7

Table 2 Frequencies and percentages of plaque index scores Table 4 Mean value, standard deviation, and frequency
(possible score 0–3), calculus index scores (possible score 0–1), distribution (percentages) of marginal bone change between 1
gingival index scores (possible score 0–3), bleeding index scores month after restoration placement (T1) and 1 year in function
(possible score 0–3), and mean value and standard deviation of (T12)
probing depth (in mm) 1 month after restoration placement (T1) Bone change (mm) n = 11
and after 1 year (T12) mean (SD) − 0.17 mm (0.73)
T1 (n = 15) T12 (n = 11)
> − 2.0 to − 1.5 1 (9.1)
Plaque index Score 0, 15 (100%) Score 0, 11 (100%)
> − 1.5 to − 1.0 0 (0.0)
Calculus index Score 0, 15 (100%) Score 0, 11 (100%)
> − 1.0 to − 0.5 2 (18.2)
Gingival index Score 0, 15 (100%) Score 0, 11 (100%)
> − 0.5 to 0.0 4 (36.4)
Bleeding index Score 0, 15 (100%) Score 0, 10 (91%)
Score 1, 1 (9%) > 0.0 to 0.5 2 (18.2)

Probing depth in mm (sd) 2.0 (0.9) 1.9 (0.8) > 0.5 to 1.0 2 (18.2)

The implant survival rate was 73.3% after 1 year in

the restoration surfaces and no infection present as function. The performance of immediate placements in
expressed with the gingival index. Some minor bleeding post-extraction sites was also analysed in the Cafiero
on probing was present in only one patient. The mean et al., Atieh et al., Tallarico et al., and Checchi et al. pro-
probing depth was 1.9 mm (SD 0.8 mm) at the 1-year spective 1-year studies [15, 20–22]. They reported a 1-
follow-up. The mean marginal bone level at the 1- year implant survival rate of 100%, 66.7%, 100%, and
month evaluation session (T1) was 0.94 ± 0.54 mm api- 89.4%, respectively. In the present study, an implant
cally of the neck of the implant (Table 3). The mean loss diameter of 4.3 mm was used in all the patients; the
of marginal bone between 1 month after restoration aforementioned studies used implant diameters of 4.8
placement (T1) and 1-year post-loading (T12) was 0.17 ± mm, 8–9 mm, 7 mm, and 6–8 mm, respectively. The
0.73 mm (Table 4). One patient’s restoration became Atieh et al. [15] implant survival rate was the lowest
loose, which could be solved by retightening the screw. (66.7%) and comparable with the survival rate in the
No other complications occurred during the 1-year present study, but it must be mentioned that the implant
evaluation period. The questionnaire revealed that only placement was combined with immediate provisionaliza-
one patient evaded eating with the implant-supported tion, whereas in the other studies, the implants were re-
restoration and that all patients were satisfied with stored after 3–6 months. It was reported that implant
colour and form of crown and surrounding mucosa. The stability in healed bone in the early postoperative period
patients mean overall satisfaction was 9.0 ± 0.6 from a is positively influenced by the macro-thread design. A
scale of 1 to 10 at the 1-year evaluation (Table 5). large thread depth with sharp thread edges and a small
Success rate, as calculated from the criteria of success as thread pitch (distance between two threads) gives higher
proposed by Albrektsson et al. [18], was 73.3%. implant stability than a small thread depth with v-
Table 5 Patient’s satisfaction 12 months (T12) after restoration
Discussion
placement
Immediate placement of regular diameter implants in
Agreement percentage
molar post-extraction sites of the maxilla and mandible (n = 11)
resulted in a high implant failure rate during a 1-year Presence of shame 0.0
follow-up period.
Self-confidence has decreased 0.0
Evades eating with the implant 9.1
Table 3 Mean value, standard deviation, and frequency
The ability to chew has decreased 0.0
distribution (percentages) of marginal bone level at 1 month
after restoration placement (T1) Implant influences speech 0.0

Bone level (mm) n = 15 Implant influences taste 0.0

Mean (SD) − 0.94 mm (0.54) Not satisfied with the colour of the crown 0.0
> − 2.5 to − 2.0 1 (6.7) Not satisfied with the form of the crown 0.0
> − 2.0 to − 1.5 2 (13.3) Not satisfied with the colour of the mucosa 0.0
around the crown
> − 1.5 to − 1.0 4 (26.7)
Not satisfied with the form of the mucosa 0.0
> − 1.0 to − 0.5 5 (33.3) around the crown
> − 0.5 to 0.0 3 (20.0) Overall satisfaction (possible score 0–10) 9.0 ± 0.6
Meijer and Raghoebar International Journal of Implant Dentistry (2020) 6:3 Page 6 of 7

shaped edges and large thread pitch [23, 24]. Finding associated with the claimed soft-tissue attachment po-
enough primary stability in molar post-extraction sites tential. An advantage of screw-retained restorations is
may be difficult because of the thin interradicular bony the absence of a microgap at the interface of the crown
septum. However, it is claimed that wide and ultra-wide and abutments and the absence of possible cement rem-
diameter implants can be used in post-extraction molar nants in the area of the peri-implant soft tissues. The
sites to overcome this lack of primary stability [14]. All use of abutments with angulated screw channels could,
the failed implants of the present study became mobile as a consequence of its design, promote soft tissue
within 6 months after functional loading. It can be as- health. In addition, the high patient compliance to the
sumed that, notwithstanding the initial primary stability prescribed post-treatment oral hygiene instructions
of more than 45 Ncm, impaired healing with too less ini- could have played an important role in the observed very
tial contact between implant and bone was the main rea- healthy peri-implant soft tissues.
son for the failures. In the present study, implants were In an attempt to incorporate the concept of patient
used implants with a large thread depth, sharp thread engagement, this study investigated the patients’ satisfac-
edges, but with a regular thread pitch and a regular tion with the rehabilitated posterior region by assessing
diameter. The Cafiero et al., Tallarico et al., and Checchi specific patient-centred outcomes. This was done by the
et al. prospective 1-year delayed loading studies [20–22] patients filling out the established questionnaire 1 year
used wide or ultra-wide diameter implants with a small after restoration placement [26, 27]. All the questioned
thread pitch. This difference might be the reason for the outcome measures showed high patient satisfaction
much lower implant survival rate in the present study. which is similar to the level reported in comparable
The mean marginal bone level was 0.94 mm below the studies with single tooth replacements in the posterior
neck of the implant at 1 month after restoration place- region and using the same questionnaire [26, 27]. Suc-
ment (T1). The optimal position of the peri-implant bone cess rate in the present study, being 73.3%, was compar-
after a maturation period should be at the same level as able with the calculated success rate in the study of
the neck of the implant. This means that part of the bio- Atieh et al. [15], being 66.7%.
logical width of the present study, which is acting as a bar- A limitation of the pilot study is the small sample size.
rier, was in contact with the implant surface roughness Nevertheless, the results are worthwhile mentioning. As
and was therefore more prone to biofilm formation, soft to whether wider implants, with a small thread pitch,
tissue infection, and peri-implantitis. Apparently, the large would have given better results within this study proto-
gap between the socket wall and the regular diameter im- col is still under debate and should be explored with a
plant, notwithstanding the local augmentation procedure, larger study population. In addition, the inherent lack of
did not fill completely during healing which led to a com- a control group associated with a case series study is an-
promised bone level. The Checchi et al. [22] study also other factor that needs to be taken into account. Fur-
mentioned that the bone level at the commencement of thermore, even though the 1-year follow-up period is
loading was 0.43 mm apically of the implant neck, possibly enough to indicate early implant failures and short-term
confirming the idea that better initial bone levels are restorative complications, it is considered to be a short
reached with wider implants. post-treatment evaluation period.
The mean change of the marginal bone height during
the 1-year follow-up was − 0.17 mm, which is very lim-
ited. The Tallarico et al. and Checchi et al. studies’ peri- Conclusion
implant bone loss [21, 22] was 0.23 mm and 0.68 mm re- Within the limitations of this study, it has been demon-
spectively, from initial loading to the 1-year evaluation. strated that immediate placement of regular diameter
Apparently, after the period of healing and maturation implants in molar post-extraction sites of maxilla and
peri-implant, bone levels remain rather stable. mandible resulted in a high implant failure rate during a
Zirconia restorations are presumed to be highly bio- 1-year follow-up period.
compatible and can potentially attach to soft-tissue. It is
claimed that zirconia promotes the attachment of hu- Acknowledgements
man gingival fibroblasts in vivo, which is desirable be- Not applicable.
cause it mimics tooth cementum’s ability to attach to
gingiva, forming the junctional epithelium [25]. With re-
Authors’ contributions
spect to the evaluation items of the peri-implant soft tis- HJAM has the following contributions: (1) data collection, concept/design,
sues of the present study, the findings are consistent statistics, and data analysis/interpretation, (2) drafting of the article, (3) final
with a healthy status, confirming the high biocompatibil- approval, and (4) accountable for all aspects of the work. GMR has the
following contributions: (1) concept/design and data analysis/interpretation,
ity of the material. The limited probing depth (mean (2) surgery, (3) critical revision of article, (4) final approval, and (5)
value of 1.9 mm at the 1-year evaluation) is possibly accountable for all aspects of the work.
Meijer and Raghoebar International Journal of Implant Dentistry (2020) 6:3 Page 7 of 7

Funding 11. Demircan S, Çankaya AB. Is immediate implant placement possible in the
An unrestricted grant from Nobel Biocare Services AG funded the 1-year clin- maxillary molar area? An anatomical study. Quintessence Int. 2016;47:853–9.
ical study; implant materials were provided (study code: 2015-1365). https://doi.org/10.3290/j.qi.a36886.
12. Atieh MA, Payne AG, Duncan WJ, de Silva RK, Cullinan MP. Immediate
Availability of data and materials placement or immediate restoration/loading of single implants for molar
The datasets used and/or analysed during the current study are available tooth replacement: a systematic review and meta-analysis. Int J Oral
from the corresponding author on reasonable request. Maxillofac Implants. 2010;25:401–15.
13. Ketabi M, Deporter D, Atenafu EG. A systematic review of outcomes
following immediate molar implant placement based on recently published
Ethics approval and consent to participate studies. Clin Implant Dent Relat Res. 2016;18:1084–94. https://doi.org/10.
This clinical study was conducted in accordance with the World Medical 1111/cid.12390.
Association Declaration of Helsinki (version VI, 2002). The Medical Ethical 14. Vandeweghe S, Hattingh A, Wennerberg A, Bruyn HD. Surgical protocol and
Committee of the University Medical Center Groningen considered this case short-term clinical outcome of immediate placement in molar extraction
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Act (Number M15.184100). The study was registered at the Netherlands Trial doi.org/10.5037/jomr.2011.2301.
Register (Number NL8117). After receiving approval, the subjects were 15. Atieh MA, Alsabeeha NH, Duncan WJ, de Silva RK, Cullinan MP, Schwass D,
examined, and all participants provided written informed consent. Payne AG. Immediate single implant restorations in mandibular molar
extraction sockets: a controlled clinical trial. Clin Oral Implants Res. 2013;24:
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