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 495

Immediate Implant Placement in

Single-Tooth Molar Extraction Sockets:
A 1- to 6-Year Retrospective Clinical Study

Francesco Amato, MD, DDS, PhD1 The use of dental implants to re-
Giorgio Polara, DDS2 place single teeth has been well
documented and shows high surviv-
al rates and predictable results. The
protocol for the standard staged ap-
proach recommends 2 to 3 months
The aim of this study was to investigate the survival rate of implants immediately of alveolar ridge healing after the
placed in fresh extraction sockets of molars in the maxilla and mandible extraction prior to implant insertion;
with a single-stage procedure. A total of 102 patients were treated, and 107 this results in an increased treatment
implants (53 in the maxilla and 54 in the mandible) were placed in a fresh
time and more discomfort for the
molar extraction socket and connected to a healing abutment. After a mean
follow-up of 3 years (range: 1 to 6 years) 1 implant failed, for a cumulative patient.1 The immediate extraction
success rate of 99.06% (98.11% for the mandible and 100% for the maxilla). placement procedure provides simi-
The results of this study support placement of an implant immediately lar results with minimal discomfort
after the extraction of a molar, applying a single-stage procedure. Int J and shorter treatment time.2
Periodontics Restorative Dent 2018;38:495–501. doi: 10.11607/prd.3179 One criterion for the success of
immediate placement is the possi-
bility of achieving primary stability.
The clinical application was initially
limited to anterior teeth. The shape
of the alveolus of a single-rooted
tooth allows the conical implant to
engage the alveolar walls, leading
to good adaptation.3,4 Immediate
replacement of an anterior tooth has
the main advantages of maintain-
ing the soft tissue architecture and
reducing volumetric tissue chang-
es due to postextraction alveolar
bone resorption, thus fulfilling the
patient’s esthetic expectation.5–7 In
1Visiting Professor, Department of Periodontology, Columbia University, recent years, immediate placement
New York, New York, USA; Clinical Professor, Master of Periodontology, has been extended to molar sites
Universitat Internacional de Catalunya, Barcelona, Spain; Private Practice,
Catania, Italy.
to maintain the tissue morphology,
2Private Practice, Modica, Italy. reducing the invasiveness, discom-
fort, and treatment time.6 In addi-
Correspondence to: Dr Francesco Amato, Viale A De Gasperi 187 Catania, Italy 95127.
tion, immediate implant placement
Fax: +39-095388585. Email: dr.amatofrancesco@libero.it
in fresh extraction sockets may limit
©2018 by Quintessence Publishing Co Inc. the extent of bone remodeling and

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496
60
Distribution (n)
58
45
43
30
15
0 of a combined piezoelectric osteo-
10 mm 11.5 mm
Implant length
Fig 1 Implant distribution by size.
reduce the need for augmentation
procedures.6,8 Adequate primary
stability during implant insertion in
single-rooted fresh extraction sites
can be achieved by selecting an
implant of an appropriate diameter
and length to engage the alveolar
walls or extending the osteotomy
preparation to the bone beyond the
apex of the tooth.3,4
Achieving optimal primary sta-
bility in fresh molar extraction sites
represents a more difficult chal-
lenge for the operator because of
the morphology of the molar alveoli
and because it usually is not pos-
sible to extend the site preparation
beyond the root apices due to the
presence of anatomical structures
such as the inferior alveolar canal
in the mandible or the sinus floor in
the maxilla.9 To achieve primary sta-
bility in a molar site, it is crucial to
maintain the integrity of the interra-
dicular bone septum. Thus, a gentle
extraction, separating the roots,
and an atraumatic site preparation
are essential for successful implant
placement.10 To minimize interradic-
ular alveolar septum damage and to
precisely prepare the implant oste-
otomy, the site preparation can be
done using the recently introduced
Piezosurgery technique.11,12
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The aim of this retrospective
clinical study is to evaluate the sur-
vival rates of implants placed in
fresh molar extraction sockets, pre-
paring the osteotomy with the use
6
13 mm
tomes/drills sequence and immedi-
ately inserting a healing abutment in
a single-stage procedure.
Materials and Methods
Between January 2009 and June
2015, patients needing extraction
and replacement of a single man-
dibular or maxillary first or second
molar were consecutively recruited
to participate in this prospective
clinical study. Reasons for extraction
included decay, fracture, or end-
odontic failure. All included teeth
had to be in good periodontal con-
dition. Smoking was not considered
to be an exclusion criterion, nor was
the presence of a periapical lesion.
However, patients were excluded
for presence of an abscess, a drain-
ing fistula, or any pus or exudate;
uncontrolled diabetes or any other
systemic condition that was a con-
traindication to surgery; or presence
of any pathology involving the adja-
cent teeth.
All subjects were thoroughly in-
formed about the risks associated
with the procedure and signed a
consent form. A complete intraoral
examination was given to each pa-
tient, impressions were taken, and
study casts were mounted on an
articulator. Computed tomographic
(CT) or cone-beam CT scans were
obtained and used for preoperative
three-dimensional analysis of the
alveolar site. Based on the obtained
information, diagnostic wax-ups
were made and surgical templates
were fabricated.
Antibiotic prophylaxis (1 g
amoxicillin twice a day for 6 days) was
started 24 hours before surgery. Lo-
cal anesthesia was induced with ar-
ticaine 4% with adrenaline 1:100,000
in the vestibular and lingual area.
No flap was raised at any of the
sites, and each tooth was extracted
atraumatically using a diamond burr
and designing an odontotomy to
separate the roots, taking care to
preserve the interradicular septum
and all the alveolar walls. After roots
extraction, thorough debridement
of the alveolus was carried out with
an alveolar curette. The osteotomy
preparation was performed using
piezosurgical tips up to 3 mm diam-
eter and thereafter the standard drill-
ing sequence following the implant
manufacturer’s protocol, using coni-
cal drills for the mandible and os-
teotomes for the maxilla. To achieve
high insertion torque (> 50 Ncm) and
improve the primary stability, the os-
teotomies were undersized using a
final drill or osteotome of the same
diameter as the implant but one
size shorter than the implant length.
The implants used in the study were
5 mm in diameter tapered implants
with lengths of 10, 11.5, and 13 mm
(Biomet 3i) (Fig 1).
All implants were inserted using
a motor unit, and the final seating was
obtained with a calibrated torque
hand ratchet (Biomet 3i) to evaluate
and record the final insertion torque
value. In all the cases where a buc-
cal gap was present between the im-
plant and the buccal wall, a collagen

sponge (Gingistat, Gaba) was insert-
ed to fill the void. Horizontal mattress
sutures were used to stabilize the col-
lagen sponges.
For all the implants, a healing
abutment with a 4-mm platform
(platform switching) and expanded
to a 6.0- or 7.5-mm-wide body (EP
One-Piece, Biomet 3i) were used.
The healing abutment screw was
immediately inserted and torqued
to 10 Ncm using a calibrated hand
torque driver.
After the surgery, patients were
instructed to consume a liquid diet
for the first week and to refrain from
chewing at the implant site for the
following 6 to 8 weeks. They also
were instructed to use a 0.20%
chlorhexidine mouthrinse three
times a day. Patients were recalled
for follow-up visit at 1-week intervals
for the first month and once a month
thereafter for the first 3 months.
Prosthetic Procedure
A final impression was made 4 to
6 months after implant placement
using a custom tray, a pick-up cop-
ing (Biomet 3i), and low-viscosity
polyether impression material (Im-
pregum Penta, 3M ESPE). Defini-
tive gold universal clearance limited
abutments (Biomet 3i) were con-
nected to all the implants. All the
definitive restorations were screw-
retained. Once inserted, the gold
screw abutment was torqued to
20 Ncm for internal connection im-
plants and 32 Ncm for external con-
nection implants, using a calibrated
torque driver as recommended by
the manufacturer.
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Patients were recalled every 6
months thereafter to monitor the
implant condition. At each recall ap-
pointment, periapical radiographs
were taken to detect any bone loss.
Implants were considered well in-
tegrated if no mobility was pres-
ent and < 3 mm of bone loss was
detected. They were considered
healthy if no signs or symptoms of
inflammation were present. Restora-
tions were considered successful if
< 1 mm of recession developed.
Figures 2 and 3 demonstrate
two typical treatments administered
to the study subjects in a maxillary
and a mandibular case.
Results
A total of 102 patients (50 men
and 52 women) participated in the
study. Of these, 62 were nonsmok-
ers and 40 were smokers. They re-
quired replacement of a total of 107
molars, 59 of which presented with
periapical lesions. In 99 patients,
one site required extraction, 2 pa-
tients had two sites, and 1 patient
had three. None of the study sites
were adjacent.
The implant distribution was
as follows: 53 in the maxilla (41 first
molars; 12 second molars) and 54 in
the mandible (49 first molars; 5 sec-
ond molars). Implant distribution by
site is shown in Fig 4. Implant dis-
tribution by diameter and length is
shown in Fig 1. Table 1 presents the
insertion torque values recorded for
all the implants placed.
The mean follow-up time was
3 years (range: 1 to 6 years): 20 im-
plants with a 1-year follow-up; 70
497
Table 1 Implant Insertion
Torque Values
Insertion torque (Ncm) Implants (n)
> 90 27
70–90 41
50–70 29
< 50 10
with a 2- to 5-year follow-up; and 17
with more than 5 years of follow-up.
During that time, 1 implant failed in
the mandible (4 weeks after place-
ment) for a cumulative success rate
of 99.06%. The failed implant was
removed and replaced 3 months
later, and the replaced implant sub-
sequently osseointegrated.
Discussion
Immediate implant placement in
fresh extraction sockets represents
a diffused approach to reduce
the duration and invasiveness of
the implant therapy.3,13 Immediate
provisionalization, initially used for
full-arch implant rehabilitation,14,15
has since been applied with highly
predictable results for the replace-
ment of a single tooth in the esthetic
area16,17 showing survival rates com-
parable to a standard staged ap-
proach.18,19
While many studies showed fa-
vorable implant survival rates in the
immediate replacement of a single-
rooted tooth,17 a reduced survival
rate was observed in the posterior
area.10,18,20 These results are nega-
tively affected by anatomical limi-
tations, such as poor bone quality
Volume 38, Number 4, 2018
498

a b c

d e f

Fig 2 Case involving a hopeless

maxillary molar. (a) Presurgical occlusal
view. (b) Occlusal view after extraction.
(c) Osteotomy preparation with
Piezosurgery. (d) Osteotomy enlargement
with osteotomes. (e) Occlusal view of
the osteotomy. (f) Implant inserted.
(g) Collagen sponges to fill up the alveolar
gap. (h) Postoperative radiograph. (i) Buccal
view at 5 years of follow-up. (j) Radiograph
g h at 5 years of follow-up.

i j

and the presence of anatomical
structures such as the maxillary si-
nus or the mandibular canal that
reduce the amount of bone apical
to the roots to engage with the im-
plant. Biomechanical condition also
appears to be unfavorable in the
posterior area. The presence of the
highest peak of forces during chew-
ing and the discrepancy between
the diameter of the crown occlusal
table and the implant diameter can
also result in an off-axis force, creat-
ing a buccolingual and distomesial
cantilever effect.21
In 2008, Fugazzotto10 reported
placing a total of 341 implants in
mandibular molar sites to replace

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 499

a b c

Fig 3 Case involving a hopeless

mandibular molar. (a) Presurgical
occlusal view. (b) Occlusal view after
extraction. (c) Implant inserted. (d)
Collagen sponge to fill the alveolar
gap. (e) Postoperative radiograph. (f)
Buccal view at 5 years of follow-up. (g)
Radiograph at 5 years of follow-up.

d e

f g

hopeless teeth. After raising The author conducted a simi-

a flap, tooth hemisection and lar study on the replacement Maxilla
single-root atraumatic extrac- of single maxillary molars and Mandible
tion were performed. The obtained comparable survival 50
Distribution (n)

implant was placed in the in- rates (99.5%).20 40

terradicular septum. Implants
were followed in function for
72 months (mean time of 30.8
months), showing high survival
rates (99.1%) and a high pre-
dictably of the technique if the
protocol was strictly followed.
Peñarrocha-Diago et al,18 30
in a 2012 study, compared the 20
survival rates of 542 implants 10
placed in mature bone with 480 0
First molar Second molar
implants placed in fresh extrac-
tion sockets and found similar
implant survival values. In this Fig 4 Implant distribution by site.

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500
study, a statistically lower survival
rate was found for implants im-
mediately inserted in the posterior
maxilla.18
It has been demonstrated an
optimal primary stability at the time
of implant insertion that can reduce
the risk of micromovements at the
implant-bone interface.22 The inser-
tion torque value is one of the main
parameters to easily evaluate im-
plant primary fixation. In 2005, Ot-
toni et al23 evaluated the relationship
between single-tooth implant sur-
vival and placement torque. In this
study, a low insertion torque value
was associated with high risk poten-
tial for biomechanical failures of im-
mediately inserted implants. Khayat
et al,24 in a 2013 study, showed that
high insertion torque (up to 176
Ncm) can avoid the risks of implant
failure, maintaining similar marginal
bone resorption with the implant in-
serted with a lower torque.
A human histologic study dem-
onstrated that high insertion torque
for an immediately loaded implant
in the molar area does not negative-
ly interfere with osseointegration,
ensuring an optimal primary stabil-
ity and contributing to successful
osseointegration with high bone-
to-implant contact and without
disturbance of the local bone micro-
circulation early in healing.25
Several studies have demon-
strated that maintaining the periosti-
um attached to the crestal bone can
dramatically reduce bone resorption
after tooth extraction.26 The use of a
flapless technique allows reduction
in discomfort for patients, surgical
steps needed, and treatment time,
allowing for immediate conditioning
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of the soft tissue and development
of the correct profile during the first
phase of healing.27
In molar extraction sites, achiev-
ing primary stability at implant in-
sertion is challenging due to the
shape of the alveolus and the pres-
ence of the anatomical structures
beyond the apex of the molar.28 In
most cases, the interradicular sep-
tum represents the ideal area for an
optimal implant position.10,20 Drilling
the osteotomies directly through
the teeth’s initially retained root
complexes could help with precise
positioning and angulation of the
implant bed preparation, enabling
ideal implant positioning during im-
mediate placement at multirooted
extraction sites.29
A classification of the surgical
sites for immediate implant insertion
in the molar area was presented by
Smith and Tarnow in 2013.28 In this,
study a surgical protocol was pro-
posed based on socket classifica-
tion. Primary stability and presence
of the buccal plate are required
when immediate implant placement
is planned; otherwise, a delayed ap-
proach is recommended.10
Sometimes hopeless molars
present with periapical lesions,
which have been considered a con-
traindication to immediate implant
placement due to possible implant
contamination.30 Several recent
studies have shown that implants
can be immediately placed in in-
fected sites with predictable results
if proper decontamination of the
site has been performed.31 Blus et
al,32 in a 2015 study, showed that
the survival rates of immediate im-
plants placed in infected and non-
infected fresh extraction sockets
were not influenced by the presence
of an acute or chronil infection. In
this study, the osteotomy was per-
formed with a Piezosurgery device
to simultaneously accomplish an
atraumatic extraction and a bacteri-
cidal effect on the cavitation.
Piezoelectric devices were de-
veloped in response to the need for
greater precision and safety of use
and were applied in oral surgery to
design the lateral window for the
sinus lift and for the osteotomy in
the split-crest technique.12,33 More
recently, new piezosurgical tips have
been introduced for preparation of
the implant osteotomy.11 The main
advantages are the ability to obtain
a precise osteotomy and reduced
risk of damage to critical anatomical
structures.34
Conclusions
Immediate placement of implants in
molar extraction sites may be a vi-
able alternative to the conventional
staged protocol. However, several
clinical parameters must be con-
sidered if this treatment option is
to succeed. Along with careful case
selection, the surgical and pros-
thetic protocols must be closely
followed. Additional studies with
larger sample size are needed for
further validation.
Acknowledgments
The authors reported no conflicts of interest
related to this study.

References
1. Albrektsson T, Brånemark PI, Hansson
HA, Lindström J. Osseointegrated ti-
tanium implants. Requirements for
ensuring a long-lasting, direct bone-to-
implant anchorage in man. Acta Orthop
Scand 1981;52:155–170.
2. Rosenquist B, Grenthe B. Immediate
placement of implants into extraction
sockets: Implant survival. Int J Oral Max-
illofac Implants 1996;11:205–209.
3. Hämmerle CH, Chen ST, Wilson TG
Jr. Consensus statements and recom-
mended clinical procedures regarding
the placement of implants in extraction
sockets. Int J Oral Maxillofac Implants
2004;19(suppl):s26–s28.
4. Lazzara RJ. Immediate implant place-
ment into extraction sites: Surgical and
restorative advantages. Int J Periodon-
tics Restorative Dent 1989;9:332–343.
5. Kois JC. Predictable single tooth peri-
implant esthetics: Five diagnostic keys.
Compend Contin Educ Dent 2001;22:
199–206.
6. Chu SJ, Salama MA, Salama H, et al. The
dual-zone therapeutic concept of man-
aging immediate implant placement
and provisional restoration in anterior
extraction sockets. Compend Contin
Educ Dent 2012;33:524–534.
7. Schropp L, Wenzel A, Kostopoulos L,
Karring T. Bone healing and soft tissue
contour changes following single-tooth
extraction: A clinical and radiographic
12-month prospective study. Int J Peri-
odontics Restorative Dent 2003;23:
313–323.
8. Evans CD, Chen ST. Esthetic outcomes
of immediate implant placements. Clin
Oral Implants Res 2008;19:73–80.
9. Atieh MA, Payne AG, Duncan WJ, de Silva
RK, Cullinan MP. Immediate placement or
immediate restoration/loading of single
implants for molar tooth replacement:
A systematic review and meta-analysis.
Int J Oral Maxillofac Implants 2010;
25:401–415.
10. Fugazzotto PA. Implant placement at
the time of mandibular molar extraction:
Description of technique and prelimi-
nary results of 341 cases. J Periodontol
2008;79:737–747.
11. Blus C, Szmukler-Moncler S. Atraumatic
tooth extraction and immediate implant
placement with piezosurgery: Evalu-
ation of 40 sites after at least 1 year of
loading. Int J Periodontics Restorative
Dent 2010;30:355–363.
© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
12. Vercellotti T, De Paoli S, Nevins M. The
piezoelectric bony window osteotomy
and sinus membrane elevation: Intro-
duction of a new technique for sim-
plification of the sinus augmentation
procedure. Int J Periodontics Restor-
ative Dent 2001;21:561–567.
13. Werbitt MJ, Goldberg PV. The imme-
diate implant: Bone preservation and
bone regeneration. Int J Periodontics
Restorative Dent 1992;12:206–217.
14. Salama H, Rose LF, Salama M, Betts NJ.
Immediate loading of bilaterally splint-
ed titanium root-form implants in fixed
prosthodontics—A technique reexam-
ined: Two case reports. Int J Periodon-
tics Restorative Dent 1995;15:344–361.
15. Tarnow DP, Emtiaz S, Classi A. Imme-
diate loading of threaded implants at
stage 1 surgery in edentulous arches:
Ten consecutive case reports with 1- to
5-year data. Int J Oral Maxillofac Im-
plants 1997;12:319–324.
16. Wöhrle PS. Single-tooth replacement in
the aesthetic zone with immediate pro-
visionalization: Fourteeen consecutive
cases reports. Pract Periodontics Aes-
thet Dent 1998;10:1107–1114.
17. Kan JY, Rungcharassaeng K, Lozada J.
Immediate placement and provisional-
ization of maxillary anterior single im-
plants: 1-year prospective study. Int J
Oral Maxillofac Implants 2003;18:31–39.
18. Peñarrocha-Diago M, Demarchi CL,
Maestre-Ferrín L, Carrillo C, Peñarrocha-
Oltra D, Peñarrocha-Diago MA. A retro-
spective comparison of 1,022 implants:
Immediate versus nonimmediate. Int J
Oral Maxillofac Implants 2012;27:421–427.
19. Quirynen M, Van Assche N, Botticelli
D, Berglundh T. How does the timing of
implant placement to extraction affect
outcome? Int J Oral Maxillofac Implants
2007:22(suppl):s203–s223.
20. Fugazzotto PA. Implant placement at
the time of maxillary molar extraction:
Treatment protocols and report of re-
sults. J Periodontol 2008;79:216–223.
21. Rangert B, Krogh PH, Langer B, Van
Roekel N. Bending overload and implant
fracture: A retrospective clinical analy-
sis. Int J Oral Maxillofac Implants 1995;
10:326–334.
22. Romanos GE, Toh CG, Siar CH, Wicht H,
Yacoob H, Nentwig GH. Bone-implant
interface around titanium implants
under different loading conditions:
A histomorphometrical analysis in the
Macaca fascicularis monkey. J Periodon-
tol 2003;74:1483–1490.
23. Ottoni JM, Oliveira ZF, Mansini R, Ca-
bral AM. Correlation between place-
ment torque and survival of single-tooth
implants. Int J Oral Maxillofac Implants
2005;20:769–776.
501
24. Khayat PG, Arnal HM, Tourbah BI,
Sennerby L. Clinical outcome of den-
tal implants placed with high insertion
torques (up to 176 Ncm). Clin Implant
Dent Relat Res 2013;15:227–233.
25. Amato F, Polara G, Traini T. Human his-
tologic analysis of an immediately load-
ed single-tooth mandibular first molar
implant. Int J Periodontics Restorative
Dent 2015;35:499–505.
26. Wood DL, Hoag PM, Donnenfeld OW,
Rosenfeld LD. Alveolar crest reduction
following full and partial thickness flaps.
J Periodontol 1972;43:141–144.
27. Campelo LD, Camara JR. Flapless im-
plant surgery: A 10-year clinical retro-
spective analysis. Int J Oral Maxillofac
Implants 2002;17:271–276.
28. Smith RB, Tarnow DP. Classification of
molar extraction sites for immediate den-
tal implant placement: Technical note.
Int J Oral Maxillofac Implants 2013;28:
911–916.
29. Rebele SF, Zuhr O, Hürzeler MB. Pre-
extractive interradicular implant bed
preparation: Case presentations of a
novel approach to immediate implant
placement at multirooted molar sites.
Int J Periodontics Restorative Dent 2013;
33:89–96.
30. Quirynen M, Gijbels F, Jacobs R. An infect-
ed jawbone site compromising success-
ful osseointegration. Periodontol 2000
2003;33:129–144.
31. Siegenthaler DW, Jung RE, Holderegger
C, Roos M, Hämmerle CH. Replacement
of teeth exhibiting periapical pathology
by immediate implants: A prospective,
controlled clinical trial. Clin Oral Im-
plants Res 2007;18:727–737.
32. Blus C, Szmukler-Moncler S, Khoury P,
Orrù G. Immediate implants placed in
infected and noninfected sites after
atraumatic tooth extraction and place-
ment with ultrasonic bone surgery. Clin
Implant Dent Relat Res 2015;17(Suppl 1):
e287–e297.
33. Anitua E, Begoña L, Orive G. Clinical
evaluation of split-crest technique with
ultrasonic bone surgery for narrow ridge
expansion: Status of soft and hard tis-
sues and implant success. Clin Implant
Dent Relat Res 2013;15:176–187.
34. Vercellotti T, Stacchi C, Russo C, et al.
Ultrasonic implant site preparation us-
ing piezosurgery: A multicenter case se-
ries study analyzing 3,579 implants with
a 1- to 3-year follow-up. Int J Periodon-
tics Restorative Dent 2014;34:11–18.
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