Luca Cordaro Clinical outcome of submerged vs.

Ferruccio Torsello
Mario Roccuzzo
non-submerged implants placed in
fresh extraction sockets

Author’s affiliations: Key words: dental implants, extraction socket, healing, immediate implants, non-
Luca Cordaro, Ferruccio Torsello, Eastman Dental submerged, submerged
Hospital, Department of Periodontics and Implant
Dentistry, Rome, Italy
Luca Cordaro, Ferruccio Torsello, Private Practice, Abstract
Rome, Italy
Mario Roccuzzo, Corso Tassoni Alessandro 14,
Aim: The aim of this study was to compare the clinical outcome of submerged vs. non-
Torino, Italy submerged tapered implants placed into fresh extraction sockets.
Materials and methods: A prospective, controlled, multicenter, randomized, clinical trial
Correspondence to:
Luca Cordaro has been performed in two centers in Rome and Torino (Italy). Thirty healthy patients were
Studio Associato Cordaro recruited according to the following inclusion criteria: need for an immediate post
Via Guido D’Arezzo 2
00198 Rome extraction implant, ages between 18 and 70, horizontal defect depth o2 mm, smokers o10
Italy cigarettes/day and absence of any circumstance or condition that could represent
Tel./Fax: þ 39 (0)6 8419797
contraindications to implant surgery. The patients were randomly allocated to submerged
e-mail: lucacordaro@usa.net
or non-submerged treatment groups immediately after flap elevation and tooth extraction.
Submerged implants were exposed 8 weeks after the first surgery; all implants were loaded
with provisional restorations 12 weeks after the first surgery and with definitive restoration
12 weeks thereafter. Clinical and radiographic parameters were evaluated at baseline, at
implant loading and at the 1-year follow-up visit.
Results: The results showed statistically significant differences between the two groups in
the mean value of keratinized tissue (KT) height after surgery that was significantly reduced
for submerged implants when compared with transmucosal implants (mean reduction of KT
at year follow-up: T group 0.2 mm, S group 1.3 mm; P ¼ 0.007).
Conclusion: Similar outcomes were found for submerged and non-submerged implants
placed in fresh extraction sockets with a horizontal peri-implant defect smaller than 2 mm,
except for a reduction of KT in the submerged group. Either with a submerged or a non-
submerged procedure, 1 mm of mean soft tissue recession is seen after 1 year when
compared with the pre-extraction situation.

Uneventful healing of implants placed im- submerged techniques with or without

Date:
Accepted 23 February 2009
To cite this article:
Cordaro L, Torsello F, Roccuzzo M. Clinical outcome of
submerged vs. non-submerged implants placed in fresh
extraction sockets.
Clin. Oral Impl. Res. 20, 2009; 1307–1313.
doi: 10.1111/j.1600-0501.2009.01724.x
mediately following tooth extraction has
been extensively reported (Lazzara 1989;
Chen et al. 2004). The earlier studies
advocated complete soft tissue closure
over the implant to guarantee osseointegra-
tion (Lazzara 1989; Becker et al. 1994).
Various surgical procedures have been
proposed for immediate implant placement
in extraction sockets: submerged or non-
guided bone regeneration (GBR).
Some studies demonstrated good results
combining submerged healing of immedi-
ate implants with GBR with non-resorb-
able or resorbable membranes (Becker &
Becker 1990; Schwartz-Arad & Chaushu
1997; Nemcovsky et al. 2000; Goldstein
et al. 2002; Chen et al. 2005) with bone
graft alone (Becker et al. 1994; Schwartz-

c 2009 John Wiley & Sons A/S

 1307
Cordaro et al . Submerged vs. non-submerged implants in fresh extraction sockets
Arad & Chaushu 1997) or with no aug-
mentation at all (Becker et al. 1998; Pao-
lantonio et al. 2001; Covani et al. 2003,
2007). Non-submerged immediate place-
ment in extraction sockets has been pro-
posed later. Insertion of non-submerged
immediate standard screw implants in
combination with GBR with non-resorb-
able or resorbable barrier membranes may
be considered safe and effective (Lang et al.
1994; Brägger et al. 1996; Hämmerle &
Lang 2001; Chen et al. 2007).
Some authors reported that horizontal
defects around immediate implants in ex-
traction sockets could heal without any
grafting or barrier procedure with a non-
submerged approach (Botticelli 2004; Chen
et al. 2007).
Studies that compare submerged and
non-submerged healing procedures for im-
plants placed in extraction sockets are lack-
ing.
There is evidence that if the horizontal
distance between the implant body and the
socket wall [horizontal defect depth
(HDD)] is o2 mm, a graft is not necessary
for implant integration (Paolantonio et al.
2001; Chen et al. 2004).Some manufac-
turers have introduced a tapered implant
design for post-extraction placement with
the aim of both reducing the distance from
the socket wall and the implant itself, and
increasing primary stability.
The aim of this study was to compare
the survival, success rate and clinical be-
havior of submerged vs. non-submerged
tapered implants placed into fresh extrac-
tion sockets presenting HDDo2 mm with-
out any augmentation procedure.
Material and methods
A prospective, controlled, multicenter,
randomized, clinical trial has been per-
formed in two centers in Rome and Torino
(Italy) in private practice settings. Patients
were recruited according to the following
inclusion criteria: need for an immediate
post extraction implant procedure (Type 1
procedure according to the ITI consensus)
(Hämmerle et al. 2004) to replace maxil-
lary incisors, canines and premolars or
mandibular canines or premolars, and age
between 18 and 70.
The exclusion criteria at the screening
visit were all the systemic diseases that
1308 | Clin. Oral Impl. Res. 20, 2009 / 1307–1313
could interfere with implant therapy, un-
controlled periodontitis, probing depth
44 mm at the adjacent teeth, inadequate
oral hygiene, heavy smoking (410 cigar-
ettes/day) and adjacent implants. It was
decided that if, at the moment of place-
ment, the horizontal distance between the
implant and the bony walls of the socket
[horizontal defect depth (HDD)] was
42 mm the patients should be included
in the category ‘intend to treat’ and should
not be evaluated for the study purposes.
The patients were asked to participate in
this study and were enrolled after meticu-
lous explanations on the study protocol and
after providing detailed answers to their
questions. All the included patients signed
an appropriate informed consent to the
treatment.
Patients received tapered (TE) implants
(Straumann Dental Implant System – In-
stitut Straumann AG, Waldemburg, CH,
Switzerland) placed immediately after
tooth extraction (Type 1 procedure accord-
ing to the ITI consensus) (Hämmerle et al.
2004).
The surgical procedure started with a
careful and minimal flap elevation with
marginal incisions. Atraumatic tooth ex-
traction was then performed with the aid of
small periotomes and, if needed, sectioning
the tooth with a bur. Great care was taken
in all these steps to avoid any damage to
the buccal bone wall.
After tooth extraction the socket was
debrided and the implant was placed with
great care in the correct prosthetic position
(Buser et al. 2004).
When the implant was placed the clin-
ician checked that primary stability was
Fig. 1. Immediate implant in the upper left second premolar extraction socket of a 38 years old woman
presenting a vertical fracture of tooth number 25. This case was randomized to the non-submerged group.
achieved (no mobility upon palpation) and
that HDD was o2 mm. If these criteria
were satisfied, the randomization envelope
was opened and the implant was assigned
to the appropriate study group. If the case
belonged to the non-submerged group (T
group) a proper healing abutment was
placed and the flap was adapted to match
with the healing abutment and sutured
(Fig. 1). If the case belonged to the sub-
merged group (S group), a cover screw was
placed, and vertical releasing incisions and
horizontal periosteal incision were per-
formed so as to mobilize the flap that was
moved coronally and sutured (Vycril, Ethi-
con, Somerville, NJ, USA) (Fig. 2).
An independent statistician generated
the randomization list with the blocks
method. The blocks of envelopes were
sent to each study center, where they
were kept by administrative employees
not involved in the treatments. The enroll-
ment was stopped when the target of 30
implants was reached. The sample size was
decided in advance by performing a sample
size calculation based on expected out-
comes of the parameters to be measured
[keratinized tissue (KT)] with a difference
of 1 mm to be detected between test and
control sites at a ¼ 0.5 and a b error ¼ 0.2.
Submerged implants were exposed 8
weeks after the first surgery with an api-
cally repositioned flap to allow the inser-
tion of a healing cap of adequate length.
All the implants of the study were loaded
with provisional restorations 12 weeks
after the first surgery and with definitive
restorations 12 weeks later (Table 1).
The following clinical parameters were
evaluated:
c 2009 John Wiley & Sons A/S


Fig. 2. Immediate implant in the upper right canine extraction socket of a 27 \s old woman. This case was
randomized to the submerged group.
Table 1. Study chart
Time Submerged group
Screening
0 Extraction, implant placement,
allocation to treatment group
8 weeks Implant exposure
12 weeks Loading with provisional
6 months Loading with definitive
12 month 6-month follow-up
18 months 12-month follow-up
 Modified plaque index (mPI) for oral
implants (Mombelli et al. 1987) was
recorded at implant provisional loading
at implant definitive loading and at 1-
year follow-up. Four measurements
were taken around each implant: me-
sial, distal, buccal and lingual/palatal.
 Peri-implant probing depth (PPD)
was measured at implant provisional
loading, at implant definitive loading
and at 1-year follow-up. Four measure-
ments were taken around each im-
plant: mesial, distal, buccal and
lingual/palatal.
 Bleeding on probing (BOP) around the
implants was measured at implant pro-
visional loading, at implant definitive
loading and at 1-year follow-up. Four
measurements were taken around each
implant: mesial, distal, buccal and
lingual/palatal.
 Height of KT, measured as the distance
from the most apical point of the gingi-
val margin to the muco-gingival line,
was recorded before tooth extraction, at
the moment of implant loading with
provisional, at implant definitive load-
ing and at 1-year follow-up.
c 2009 John Wiley & Sons A/S
 1309 |
Cordaro et al . Submerged vs. non-submerged implants in fresh extraction sockets
Non-submerged group
Screening
Extraction, implant placement,
allocation to treatment group
None
Loading with provisional
Loading with definitive
6-month follow-up
12-month follow-up
 Variation of soft tissue position (REC).
Three measurements were taken for
each implant site (Fig. 3):
 DP–IM: Distance between the distal
papilla and the adjacent tooth incisal
margin.
 GM–IM: Distance between the buccal
gingival margin and the line con-
necting incisal margins of adjacent
teeth.
 MP–IM: Distance between the mesial
papilla and the adjacent tooth incisal
margin.
These values were recorded before tooth
extraction, at implant loading with provi-
sional, at implant definitive loading and at
1-year follow-up.
The differences between the measure-
ments taken before tooth extraction and
the measurements taken at different stages
of treatment were reported as recession
values (REC).
All clinical measurements were taken in
vivo with the aid of a UNC periodontal
probe and their values were recorded to the
nearest 0.5 mm.
Fig. 3. Illustration of the measured distances for the
position of gingival margin. DP–IM, distance be-
tween distal papilla and adiacent tooth incisal mar-
gin; GM–IM, distance between buccal gingival
margin and line connecting incisal margins of adja-
cent teeth; MP–IM, distance between mesial papilla
and adjacent tooth incisal margin.
 Crestal bone levels (CBL): distances
from the implant shoulder to the most
coronal bone to implant contact mea-
sured on X-rays with a millimeter ruler
to the nearest 0.5 mm. Two measure-
ments were taken for each implant:
mesially and distally.
Clinical measurements were performed
by two different operators (one for each
center). In order to limit the inter-examiner
variability, a preliminary calibration meet-
ing was arranged before study initiation.
The investigators discussed the study para-
meters together and agreed on the same
measuring methods. Then an inter-exam-
iner reliability test was performed for the
clinical measurements: both operators in-
dependently took and recorded the studied
parameters on a sample of 10 patients with
implant-supported prostheses who were
not part of this study, but agreed to be
part of the calibration process.
The intra-examiner reliability was calcu-
lated with the Wilcoxon test separately for
the two operators recording all the clinical
parameters at the screening visit and after 1
week. This procedure was repeated at the
moment of loading with provisional re-
storation and 1 week later for the para-
meters that could not be evaluated at
baseline (such as PPD and BOP). The
same operator measured all the X-rays of
both the study centers and, consequently,
only the intra-examiner reliability test was
performed. The measurements taken on
baseline and the final X-rays were taken
twice at an interval of 2 months.
No significant mean difference was
found both for clinical and for radiographic
repeated series of measurements.
Clin. Oral Impl. Res. 20, 2009 / 1307–1313
Cordaro et al . Submerged vs. non-submerged implants in fresh extraction sockets

For numeric parameters such as PPD,
KT, REC and CBL mean, standard devia-
tion and nonparametric 95% confidence
intervals (CI) of the measurements were
calculated for each group. The comparison
within groups was performed with the
Wilcoxon test. The comparison between
different groups was performed by means of
the Mann–Whitney test. For nominal mea-
surements such as BOP and plaque index
(PI), the comparisons were made with the
aid of the w2 test or Fisher’s exact when
distributions with small frequencies were
considered.
The level of significance was set at
Po0.05. Because six endpoints were eval-
uated a Bonferroni correction has been used
(0.05/6), thus leading the level of signifi-
cance to Po0.008.
Results
Thirty implants were placed, 14 sub-
merged and 16 non-submerged. One im-
plant belonging to the non-submerged
group failed before loading. The overall 1-
year survival rate was 96.6%, being 100%
in the submerged group and 93.8 in the
non-submerged group. This difference was,
however, statistically not significant.
The failed implant was successfully re-
placed 3 months after its removal.
It should be noticed that among the 14
submerged implants placed, three demon-
strated a minimal self-exposure of the cover
screw. It is important to note that these
exposures were limited to the occlusal
portion of the mucosa and that the implant
necks were never exposed. In the afore-
mentioned three cases, the author’s choice
was to change the cover screw with the
healing cap, without the elevation of a flap.
PI
No significant differences were found in
the distribution of the PI between the two
groups at baseline and at the moment of
loading, or at the 1-year follow-up visit
(P ¼ 0.26 at provisional loading, P ¼ 0.32
at definitive loading and P ¼ 0.41 at the 1-
year follow-up visit).
PPD
PPD was recorded for the first time at the
moment of implant loading with the provi-
sional restoration. It was then recorded
again at the moment of definitive crown
placement and at the 1-year follow-up
visit. The mean PPD values were
2.7  0.67 mm (median: 3 mm; 95% CI:
2.53–2.87 mm) for the T group and
2.57  0.6 mm (median: 3 mm; 95% CI:
2.41–2.73 mm) for the S group at provi-
sional loading, 2.75  0.77 mm (median:
3 mm; 95% CI: 2.57–2.95 mm) for the T
group and 2.80  0.7 mm (median: 3 mm;
95% CI: 2.63–2.98 mm) for the S group at
the delivery of definitive restoration and
2.57  0.87 mm (median: 2 mm; 95% CI:
2.35–2.78 mm) for the T group and
2.88  1.01 mm (median: 3 mm; 95%
CI: 2.61–3.14 mm) for the S group at the
1-year follow-up visit. No statistically sig-
nificant differences were found between
the two groups at any stage of the study
in the mean PPD values (P ¼ 0.32 at
provisional loading, P ¼ 0.57 at definitive
loading and P ¼ 0.18 at the 1-year follow-
up visit).
BOP
BOP was recorded at the moment of im-
plant loading with the provisional restora-
tion, at the moment of the delivery or the
final restoration and at the 1-year follow-
up visit.
The non-submerged group showed 19%
BOP þ sites at the moment of loading with
the provisional restoration, 18% BOP þ
sites at the delivery of the final prosthesis
and 20% BOP þ sites at the 1-year follow-
up visit. The submerged group showed,
respectively, 16%, 17% and 21% BOP þ
sites at the same intervals. No statistically
significant differences in the BOP þ dis-
tribution between the study groups at any
of the different observations were found
(P ¼ 0.38 at provisional loading, P ¼ 0.47
at definitive loading and P ¼ 0.51 at the 1-
year follow-up visit).
Variation of the mucosal margin (REC)
Table 2 shows that there were no statisti-
cally significant differences between each
group’s mean values at baseline and at any
further stage of the study (P ¼ 0.47 at base-
line, P ¼ 0.4 provisional loading, P ¼ 0.61
at definitive loading and P ¼ 0.33 at the 1-
year follow-up visit). The comparisons
within each group showed that the reces-
sion of the mucosal margin after the sur-
gery was statistically significant for both
groups (P ¼ 0.001). This result demon-
strated that soft tissue recession occurred
after immediate implant placement in this
study regardless of submerged or non-sub-
merged implant healing.
Table 3 describes the frequency of mid-
facial vestibular recessions at the 1-year
follow-up visit. The differences in tissue
biotypes are also taken into consideration.

Table 2. Recession values (REC) (mm) calculated as the differences between the measurements taken before tooth extraction and at
different stages of treatment
Group Provisional loading Definitive loading 1-year follow-up
MP–IM GM–IM DP–IM Total MP–IM GM–IM DP–IM Total MP–IM GM–IM DP–IM Total
T Mean 0.93 0.73 0.8 0.82 0.8 0.73 0.8 0.78 0.83 0.73 0.63 0.73
SD 1.03 0.79 0.77 0.86 0.77 0.7 0.77 0.74 0.79 0.7 0.77 0.74
Median 1 1 1 1 1 1 1 1 1 1 0 1
95% CI 0.47/1.53 0.4/1.13 0.47/1.27 0.58/1.07 0.47/1.2 0.4/1.07 0.47/1.2 0.58/1 0.47/1.23 0.4/1.07 0.27/1 0.52/0.96
S Mean and 0.96 0.82 0.95 0.92 0.79 0.93 0.79 0.83 0.96 0.82 0.82 0.87
SD 0.69 0.54 0.79 0.67 0.57 0.62 0.73 0.63 0.49 0.67 0.77 0.64
Median 1 1 1 1 1 1 1 1 1 1 1 1
95% CI 0.64/1.36 0.54/1.07 0.57/1.36 0.71/1.12 0.5/1.07 0.64/1.21 0.43/1.18 0.64/1.01 0.71/1.21 0.5/1.14 0.47/1.25 0.67/1.07

There were no statistically significant differences in the mean REC values between submerged and non-submerged groups. The comparison within groups
demonstrated significant recession occurring at provisional loading, at definitive loading and at 1-year follow-up visits when compared with baseline
(P ¼ 0.001).
CI, confidence interval; DP, distal papilla; GM, gingival margin; IM, incisal margin; MP, mesial papilla; SD, standard deviation.

1310 | Clin. Oral Impl. Res. 20, 2009 / 1307–1313 c 2009 John Wiley & Sons A/S

 Cordaro et al . Submerged vs. non-submerged implants in fresh extraction sockets

The statistical analysis found no differ- values in the two groups was statistically in the submerged group. No statistically
ences between the two groups for the dis- significant: the non-submerged group de- significant differences in the mean CBL
tribution of tissue biotypes (P ¼ 0.71), monstrated minimal change in KT height values were found between the T and the S
showing a homogeneous composition of (0.27 mm), while the submerged group groups at any stage of the treatment
the two samples. No statistically signifi- showed 1.71 mm of KT loss (P ¼ 0.002). (P ¼ 0.28 at provisional loading, P ¼ 0.16 at
cant differences were also found between These changes were almost the same at the definitive loading and P ¼ 0.3 at the 1-year
the two groups in the distribution of reces- time of final restoration (P ¼ 0.003) and follow-up visit).
sion types (P ¼ 0.82), indicating that the were still statistically significant at the 1-
tissue healing patterns did not seem to year follow-up visit (P ¼ 0.007).
influence the extent of recession. When Discussion
both groups were pooled together in order
to determine the influence of tissue bio- CBL The aim of the present study was to com-
type on the recession amount, it has been Mean marginal bone resorption at the pare the clinical outcome of submerged vs.
found that, regardless of the tissue healing moment of provisional loading was 0.26  non-submerged TE implants placed in
pattern, implants placed in patients with a 0.34 mm (median 0.5 mm; 95% CI: 0.08– fresh extraction sockets. Because many
thin periodontal biotype showed more re- 0.46 mm) for the non-submerged group and variables may affect the clinical results of
cession than implants placed in cases of 0.46  0.4 mm (median 0.5 mm; 95% CI: implants placed in extraction sockets, the
thick periodontal tissues (P ¼ 0.03). 0.29–0.75 mm) for the submerged group. At authors attempted to limit the influence of
the definitive loading, crestal bone resorp- other factors.
tion was 0.54  0.33 mm (median 0.5 mm; For this reason, it has been decided to
Height of KT 95% CI: 0.42–0.75 mm) for T group im- select only sockets with o2 mm of HDD,
plants and 0.58  0.56 mm (median where there is evidence that augmentation
Table 4 shows the results for KT height. 0.5 mm; 95% CI: 0.28–0.91 mm) for S procedures are not necessary (Paolantonio
There was no statistically significant group fixtures. At the 1-year follow-up visit et al. 2001; Chen et al. 2004). Tapered
difference between each group’s mean va- mean bone loss was 0.54  0.33 (median implants were chosen in order to reduce
lues at baseline (P ¼ 0.47). At the time of 0.5 mm; 95% CI: 0.42–0.75 mm) in the the distance between the implant and the
implant loading with provisional restora- non-submerged group and 0.63  0.53 extraction sockets’ walls and to improve
tion, the difference between the mean KT (median 0.5 mm; 95% CI: 0.37–0.95 mm) attainment of primary stability (Akkocao-
glu et al. 2005; Lang et al. 2007).
Only one implant was lost during the
Table 3. Frequency distribution of vestibular recession at the buccal gingival margin study, belonging to the non-submerged
(GM–IP) at the 1-year follow-up group. The reason for this failure may be
Group Biotype RECo1 mm REC41 and o2 mm REC  2 mm Total related to a prosthetic overload because the
T Thick 6 2 1 9 removable prosthesis was not trimmed
Thin 1 4 1 6 sufficiently. For this reason, it is the
Total 7 6 2 15 authors’ opinion that this failure was re-
S Thick 4 3 0 7
Thin 1 4 2 7 lated to a clinical mistake rather to with
Total 5 7 2 14 the healing pattern. This implant has been
Both groups Thick 10 5 1 16 replaced successfully a few months after its
pooled together Thin 2 8 3 13
removal.
Total 12 13 4 29
The composition of the two study groups
The different distribution of soft tissue recessions was statistically significant when both groups were was homogenous, because no statistically
pooled together and the different biotypes were compared (P ¼ 0.03).
significant differences were found at the

Table 4. Height of keratinized tissue (KT) (mm) at the different stages of the study and their differences from baseline values
Group Baseline Provisional loading Definitive loading 1-year follow-up
Differ from Differ from Differ from
baseline baseline baseline
T Mean and SD 3.66  1.18 3.4  1.06  0.27  0.7 3.27  1.03  0.4  0.83 3.47  0.99  0.2  0.68
Median 4 4 0 4 0 4 0
95% CI 3.07/4.2 2.87/3.87  0.67/0 2.73/3.73  0.87/0.07 3/3.93  0.53/0.07
S Mean and SD 3.93  1.27 2.21  0.8  1.71  1.33 2.07  0.73  1.86  1.29 2.57  0.93  1.36  1.21
Median 4 2  1.5 2 2 2  1.5
95% CI 3.29/4.57 1.71/2.57  2.43/  1.14 1.64/2.36  2.43/  1.21 2.08/3.08  1.93/  0.71

There was no significant difference between the mean KT values at baseline (P ¼ 0.47). The KT loss was significantly greater in the S group when compared
with the T group at provisional loading (P ¼ 0.002), at definitive loading (P ¼ 0.003) and at the 1-year follow-up visit (P ¼ 0.007).
CI, confidence interval; SD, standard deviation.

c 2009 John Wiley & Sons A/S

 1311 | Clin. Oral Impl. Res. 20, 2009 / 1307–1313
Cordaro et al . Submerged vs. non-submerged implants in fresh extraction sockets
screening visit for any of the parameters
studied between the two groups.
Because no differences were found be-
tween the study groups in the distribution
of the mPI for oral implants at any subse-
quent stage of the study, it seems that the
different treatment modalities do not mod-
ify this outcome.
The mean PPD values did not differ
significantly between the two groups.
The mean PPD values recorded in the
present study are consistent with PPD
measurement published in previous
reports for implants inserted into healed
sites (Buser et al. 1990; Apse et al. 1991;
Salvi & Lang 2004). Also, the BOP
rate appeared to be consistent with a pre-
viously published study (Nishimura et al.
1997).
In terms of the corono-apical position of
the mucosal margin after immediate im-
plants, a previous paper reported 0.75 mm
of mean soft tissue recession (Cornelini
et al. 2005). Flapless placement of immedi-
ate implants showed 0.55 mm of mean soft
tissue recession (Kan et al. 2003). These
differences between the two studies appear
to be clinically irrelevant.
A recent study demonstrated soft tissue
recession ranging from 1 to 3 mm in one-
third of the cases, and o1 mm of recession
in the remaining two-thirds of the sample
(Chen et al. 2007).
The present study, in accordance with
previous reports, demonstrated approxi-
mately 1 mm of mean recession, regardless
of the type of treatment performed. This
outcome suggested that some recession
occurs when immediate implants are
placed, but this is not related to the sub-
merged or the non-submerged procedure.
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This study also suggested that, for soft
tissue recession, the tissue biotype could
be more important than the healing proce-
dure (P ¼ 0.034). It should be noticed that
in the present report a similar amount of
soft tissue recession was recorded at the
interproximal papillae and at the midfacial
aspect of the crown.
According to previously published stu-
dies on bone healing after extractions, ver-
tical and horizontal bone resorption is
expected, regardless of implant insertion
immediately after extraction (Covani et al.
2003, 2007; Araùjo et al. 2005). It may be
speculated that soft tissue recession may be
related to the reduction of hard tissue sup-
port found in both study groups. It should
be noticed that in the present report no
direct measurement of the buccal bone
width and height could be performed
because an implant exposure procedure
was performed only in the submerged
group.
The main statistically significant finding
in the present study is related to the height
of KT. The results of the present study
demonstrated a statistically significant
loss of KT with the submerged healing.
This was probably caused by the coronal
repositioning of the flap during the first
surgical phase that was necessary to
achieve complete wound closure.
Mean interproximal crestal bone resorp-
tion did not differ between the two study
groups, meaning that the decision regard-
ing a submerged or a non-submerged pro-
cedure does not influence this parameter. It
should be noticed that no definitive con-
clusions might be drawn for this parameter,
because the radiographs taken in the pre-
sent study were not standardized. How-
sockets: an experimental study in the dog.
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ever, great care was recommended to the
clinicians to ensure a parallel position of
the film and the implant axis using the
paralleling technique (Bragger 1994). The
mean CBL values found in our material at
the 1-year follow-up visit (0.54 mm in the
T group and 0.63 mm in the S group) are
similar to the results of previous studies,
ranging from 0.26 to 0.5 mm of bone re-
sorption (Kan et al. 2003; Cornelini et al.
2005).
Conclusions
With the limitations of the present study, it
might be concluded that immediate im-
plants placed with a submerged or a non-
submerged technique show similar success
and survival rates with similar behavior of
peri-implant hard and soft tissues, includ-
ing a mean of 1 mm of vertical reces-
sion of the papillae and the midfacial
gingival margin when compared with the
soft tissue levels before tooth extraction.
Significant reduction of the width of KT
was observed when using the submerged
approach.
The data obtained demonstrate that,
with a horizontal peri-implant defect
2 mm, there is no need to advance the
flap and choose a submerged approach.
Acknowledgements: This study has
been supported by the grant no 397/
2005 issued by the ITI foundation
(Basel, CH, Switzerland). The authors
are grateful to ITI for its support. The
authors are grateful to Prof. Giorgio
Primiceri for his valuable help with the
statistical analysis.
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