Received: 25 May 2019 Revised: 18 September 2019 Accepted: 19 September 2019

DOI: 10.1111/cid.12854

ORIGINAL ARTICLE

Immediate implant placement for a single anterior maxillary

tooth with a facial bone wall defect: A prospective clinical
study with a one-year follow-up period

Renzhang Liu MM, Doctor1 | Zhen Yang MD, Doctor2 | Jianguo Tan MD, Professor2 |
Li Chen MD, Doctor2 | Hanqing Liu MM, Doctor1 | Jianjun Yang MBBS, Professor1

1
Department of Oral and Maxillofacial Surgery,
The Affiliated Hospital of Qingdao University,
Shandong, China
2
Department of Prosthodontics, School and
Hospital of Stomatology, Peking University,
Peking, China
Correspondence
Jianjun Yang, Department of Oral and
Maxillofacial Surgery, The Affiliated Hospital
of Qingdao University, NO.16 Jiangsu Road,
Qingdao, Shandong 266071, China.
Email: yjjqd@126.com
Funding information
Qingdao Municipal Science and Technology
Bureau, Grant/Award Number: 15-9-2-73-nsh
Abstract
Background: Clinical studies on immediate implant placement for a single anterior
maxillary tooth with a facial bone wall defect are rarely reported.
Objective: To study the clinical outcomes of immediate implant placement combined
with flap surgery, guided bone regeneration and non-submerged healing for a single
anterior maxillary tooth with a facial bone wall defect.
Materials and Methods: Forty-five patients with a single failing tooth in the anterior
maxillary region showing indications for extraction combined with a facial bone wall
defect were treated by means of immediate implant placement combined with flap sur-
gery, guided bone regeneration and non-submerged healing. During this study, the
implant survival rate, soft and hard tissue dimension changes, pink aesthetic score (PAS),
and patient aesthetic satisfaction were assessed at 1, 6, and 12 months post-operatively.
Results: At 12 months post-operatively, the survival rate of 45 implants was 100%.
Mesial/distal papillary level reduction and midfacial soft tissue recession were mea-
sured as 0.53, 0.41, and 0.31 mm, respectively. The thickness of facial bone reduction
measured by cone beam computed tomography was 0.94, 0.80, 0.85, 0.82, 0.45, and
0.41 mm at 6 different sites around the implant. The mean PAS and patient aesthetic
satisfaction were determined to be 10.58% and 93%, respectively.
Conclusions: The proposed surgical procedure is a valuable treatment strategy as
assessed by preliminary clinical outcomes.

KEYWORDS
facial bone wall defect, flap surgery, GBR, immediate implant placement, non-submerged
healing

1 | I N T RO D UC T I O N
In the 1960s, Professor Brånemark founded the theory of osseointegration
1
and pioneered the modern dental implant. Over 50 years later, modern
dental implantation technology is classified as immediate implant place-
ment (type 1), early implant placement with soft tissue healing (type 2),
early implant placement with partial bone tissue healing (type 3), and late
implant placement (type 4), according to the time of implantation in a
tooth extraction site.2 In 1978, the first study of immediate implant
placement was completed by Professor Wilfried Schulte at the German
University of Tubingen, who suggested the Tubingen implant.3 After
more than 40 years of basic and clinical research, it has been shown that

Clin Implant Dent Relat Res. 2019;1–11. wileyonlinelibrary.com/journal/cid © 2019 Wiley Periodicals, Inc. 1
2 LIU ET AL.
immediate implant placement is a safe and feasible method for restoring
failing teeth.4
At the 5th ITI Consensus Conference in 2013, the following four
criteria were proposed as indications for immediate implantation:
(1) an intact labial bone wall (>1 mm); (2) a thick soft tissue biotype;
(3) no acute infection at the extraction site; and (4) adequate bone
volume at the tooth extraction site to stabilize the implant in a correct
3D position.5,6 In the implant treatment of maxillary anterior teeth,
scholars generally believe that a fully intact facial bone wall at the
extraction site is the most important requirement for immediate
7
implant placement. However, some studies using cone beam com-
puted tomography (CBCT) have shown that a thick bone wall pheno-
type is rarely present in the anterior maxilla, with approximately 4.6%
of patients having a thick wall phenotype in the central incisor area
(>1 mm).8 A recent study showed that 52% of sites in the maxillary
central incisor area presented a facial bone defect.9 In view of the
research above, a facial bone thickness of less than 1 mm and the
presence of a facial bone defect are the major concerns regarding
immediate implant placement because instability of the labial plate
may result in soft tissue recession, which would worsen the aesthetic
outcome in the anterior maxillary area. For patients with a single
failing tooth in the anterior maxillary region with indications for
extraction and a labial bone wall defect, Buser et al proposed the use
of early implant placement (type 2) combined with flap surgery,
guided bone regeneration and submerged healing after soft tissue
healing.7 This method requires three operations, namely, tooth extrac-
tion, implant insertion and soft tissue plasty. Clinical studies on imme-
diate implantation in such cases have rarely been reported. The
reason for this lack of research is that scholars have questioned imme-
diate procedures and believe that immediate implant placement at the
time of tooth extraction is associated with an increased rate of surgi-
cal complications and may result in suboptimal aesthetic outcomes.10
A recent systematic review reporting on the aesthetic outcomes of
immediate and early placed implants in the anterior maxilla found type
1 implant placement to be associated with a greater variability in
outcomes and a higher frequency of advanced recession (>1 mm) of
the midfacial mucosa (Chen & Buser).5
Immediate implant placement at the time of extraction provides
potential advantages for both clinicians and patients, reduces the
treatment time and may result in increased patient satisfaction.
For patients with a single failing tooth in the anterior maxillary area
with indications for extraction and a facial bone wall defect, the
authors applied immediate implant placement combined with flap
surgery, guided bone regeneration and non-submerged healing. In this
way, tooth extraction, implant insertion and soft tissue plasty could be
completed in only one operation. On the premise of guaranteeing the
therapeutic outcome, the authors hope to shorten the treatment cycle
and reduce the number of operations through this treatment concept.
The aim of this prospective clinical study was to evaluate the clini-
cal outcomes of immediate implant placement combined with flap sur-
gery, guided bone regeneration and non-submerged healing for a
single anterior maxillary tooth with a facial bone wall defect.
2 | MATERIALS AND METHODS
2.1 | Ethical approval
This study followed the guidelines of the revised World Medical Associ-
ation Declaration of Helsinki (2008) and was approved by the ethical
committee of the Affiliated Hospital of Qingdao University (No. QDFY
WZ 2013-3-14-02).
2.2 | Patient selection
Patients requesting immediate implant placement after tooth extrac-
tion in the anterior maxilla were recruited and enrolled between May
2014 and May 2017 in the Department of Oral and Maxillofacial Sur-
gery of the Affiliated Hospital of Qingdao University. All patients were
informed of the relevant interests and provided written informed
consent.
The inclusion criteria for this study were as follows:
• At least 18 years old.
• Good oral hygiene (full-mouth plaque score ≤25%).
• Single failing tooth in the anterior maxilla (13-23) with both neigh-
boring teeth present.
• Facial bone wall of the failing tooth defective to different degrees,
as determined by CBCT examination.
• Adequate quantity of native bone to achieve primary stability of at
least 35 N cm.
The exclusion criteria of this study were as follows:
• Untreated periodontal disease.
• Smoking.
• Acute infection around the failing tooth.
2.3 | Pre-surgical procedure
Before the surgery, oral and CBCT (i-CAT 17-19, Imaging Sciences
International, LLC, Pennsylvania) examinations were conducted by
only one clinician (Jianjun Yang) for all patients. Thereupon, a treat-
ment plan was determined. All patients underwent periodontal scaling
before surgery. An acrylic stent was made for each subject to evaluate
soft tissue changes (Figure 1). This method has been proven to be
highly reproducible. Before tooth extraction (T0), the soft tissue
parameters were recorded as a baseline.
2.4 | Surgical procedure
All patients consented to the treatment procedure. Prophylactic anti-
biotic therapy (cephalosporin and metronidazole) was administered
1 hour before the surgery. Intraoral antiseptic treatment with a
2-minutes rinse of 2.5% iodophor was then performed. After inducing
local anesthesia, the tooth was extracted by a surgical procedure with
minimal trauma to protect the alveolar bone. The facial vertical
releasing incision at the distal adjacent tooth ended beneath the
mucogingival junction to ensure that the final sutures were without
LIU ET AL.
F I G U R E 1 Acrylic stent with three directional grooves for
measuring the soft tissue changes in the mesial and distal papilla and
midfacial mucosa levels
tension. Then, the mesiodistal gingival col of the failing tooth was
incised to the crest of the alveolar ridge along the mesiodistal direc-
tion. On the facial side, a full-thickness mucoperiosteal triangular flap
was elevated, and the palatal mucoperiosteum was gently elevated to
reveal the alveolar crest. The extraction socket was debrided thor-
oughly to remove soft and hard tissue lesions. The implant bed was
prepared at the base of the socket near the palatal wall, and autoge-
nous bone was collected during socket drilling. The appropriate implant
(Superline, Dentium, South Korea) was inserted. To ensure primary sta-
bility, the stability of the implant was determined to be greater than
35 N cm using a torque controller (Superline, Dentium, South Korea).
The implant was positioned slightly closer to the palatal bone wall to
achieve screw-retained permanent restoration, leaving a 1 to 2 mm
jumping distance to the internal surface of the labial bone wall. An
appropriate healing abutment (Superline, Dentium, South Korea) with a
diameter slightly larger than that of the implant was screwed onto the
implant to a height of 1 mm higher than the mucosa after suturing.
After insertion, some of the autogenous bone chips were placed on the
exposed surface of the implant. The labial plate defect was filled with
deproteinized bovine bone particles (Bio-Oss, Geistlich Pharma AG,
Wolhusen, Switzerland) mixed autogenous bone chips; then, an absorb-
able collagen membrane (Bio-Gide, Geistlich Pharma AG, Wolhusen,
Switzerland) was placed on the bone graft materials to achieve guided
bone regeneration (GBR). When a large quantity of autogenous bone
chips was needed, autogenous bone powder was usually collected from
alveolar bone exposed in the surgical area. The facial and palatal
mucoperiosteal flaps were then closed with interrupted sutures around
the abutment without tension. After surgery (T1), CBCT (i-CAT 17-19,
Imaging Sciences International, LLC, Pennsylvania) was performed
immediately to determine the three-dimensional position of the implant
and measure the thickness of the bone graft area. The bone graft area
was compressed using the medical tape and gauze for 24 hours (figure
g in Figure 2). All surgical procedures were performed by only one sur-
geon (Jianjun Yang). On the day after surgery, a resin-bonded, fixed par-
tial denture was attached to the mesial and distal adjacent teeth as a
temporary prosthesis. After the operation, the patients received
3
antibiotic treatment with cephalosporin and metronidazole for 5 to
7 days and dexamethasone for 3 to 5 days. The patients were advised
to avoid any mechanical trauma to the surgical site. Sutures were
removed 1 week after the operation, and the condition of primary
wound closure was recorded. One month after the operation (T2), the
soft tissue parameters were recorded.
2.5 | Restorative procedure
Six months after the implant surgery (T3), permanent restorations
were made if the following conditions were met: the healing abutment
and the implant were not loose; the gingival mucosa in the surgical
area was healthy; and the adjacent and opposing teeth were normal.
The soft tissue parameters were recorded at T3.
A standard implant impression was made using a polyether
impression material (DMG, Hamburg, Germany) for the preparation of
permanent restorations. All restorations were placed on the implant
torqued to 35 N cm. All restorative procedures were completed by
the same prosthodontist (Zhen Yang) with restorations made by the
same dental laboratory.
2.6 | Clinical follow-up
Twelve months after the implant surgery (T4), all subjects underwent
a follow-up examination to record the implant survival rate and the
soft tissue parameters of the implant denture. The facial bone of the
implant was measured by CBCT (i-CAT 17-19, Imaging Sciences Inter-
national, LLC, Pennsylvania). The aesthetic outcome of 45 implant-
supported dentures was evaluated by the pink aesthetic score (PAS).
Patient aesthetic satisfaction was investigated by a visual analogue
scale (VAS). A typical case is shown in Figure 2.
2.7 | Evaluation criteria and methods
2.7.1 | Implant survival rate and complications
At T2, T3, and T4, the implant survival rate and complications were
recorded. The criteria used for successful implantation were proposed
by Buser,11 as follows:
• The implant is in its original position.
• There are no persistent complaints.
• There is no peri-implant inflammation.
• There is no implant loosening.
• There is no peri-implant radiolucency.
2.7.2 | Soft tissue parameters
After the operation, the condition of primary wound closure and the
composite wound failure index, comprising wound dehiscence, edema,
and suppuration, were recorded.
At T2, T3, and T4, the condition of the soft tissue around the
implant were recorded by means of the following parameters:
4 LIU ET AL.

F I G U R E 2 Typical case. A, Periapical X-ray showing the right central incisor with a root fracture. B, The root fracture could be
observed after extraction. C, Debridement of the extraction site. D, The labial defect could be observed. E, Bio-Oss particles mixed with
autogenous bone chips were grafted into the labial defect area. F, The surface of the bone grafts was covered with a Bio-Gide absorbable
collagen membrane. G, Local compression of the guided bone regeneration (GBR) area was applied for 24 hours after the surgery. H,
At T3 (6 months post operation), the gingival tissue was healthy. I, The periapical X-ray at T3. J, The pink aesthetic outcome (PAS: 12)
at T4 (12 months post operation). K, The periapical X-ray at T4. L, Cone beam computed tomography (CBCT) image showing labial
bone formation at T4
LIU ET AL. 5

• Plaque score. The plaque score was evaluated at four sites for each 2.7.3 | Hard tissue parameters
implant (mesial, midfacial, distal, and palatal) by a dichotomous
The facial bone for all 45 implants was measured post-operatively
score (0 = no visible plaque at the soft tissue margin; =visible
(T1) and 12 months after the implant surgery (T4) by sagittal CBCT
plaque at the soft tissue margin).
(i-CAT 17-19, Imaging Sciences International, LLC, Pennsylvania)
• Probing depth. The probing depth was evaluated to the nearest
images through the implant axis. When measuring the thickness of
0.5 mm at four sites for each implant (mesial, midfacial, distal,
the facial bone, we referred to Wang's method.12 Five sites (D1,
and palatal) using a manual probe (PCPUN156, Hu-Friedy,
D2, D3, D4, and D5) were located at an interval of 1/4 the length
Chicago).
of the implant axis (from shoulder to root apex), and lines perpen-
• Bleeding on probing. Bleeding on probing was measured at four
dicular to the long implant axis were made at each site. The hori-
sites for each implant (mesial, midfacial, distal, and palatal) by a
zontal facial bone thickness (HFBT) was defined as the distance
dichotomous score (0 = no bleeding; 1 = bleeding). At each follow-
from the facial outline of the implant to the outer surface of the
up visit, oral hygiene was improved.
facial bone on these lines. The vertical facial bone level (VFBL)
was defined as perpendicular to the distance from the shoulder of
At T0, T2, T3, and T4, the soft tissue dimensions of the implant
the implant platform to the most coronal point of the facial bone,
site were measured, as follows:
parallel to the axis of the implant. From the baseline of the implant
shoulder platform, the VFBL was recorded as a positive or negative
• Papillary level. An acrylic stent with directional grooves was
value when the most coronal point of the facial bone was located
used to evaluate the mesial and distal papillary levels (Figure 1).
coronal or apical to the implant coronal platform, respectively.
The papillary level was defined as the distance between the top
These measurement lines are shown in Figure 3. All sagittal CBCT
of the groove and the top of the papilla measured to the
images were exported to image analysis software (ImageJ 1.43 μ,
nearest 0.5 mm using a manual probe (PCPUN156, Hu-Friedy,
NIH, Bethesda, Maryland); each of the measuring lines was
Chicago).
depicted, and the length of each measuring line was calculated
• Midfacial mucosa level. The midfacial mucosa level of the tooth/
according to the known implant length as a reference.
restoration was measured using the same acrylic stent with a cen-
To ensure the reliability of the CBCT-based measurements, two
tral directional groove. The midfacial level was defined as the dis-
calibrated examiners (Hui Zhao and Lu Liu) who were not involved
tance between the top of the groove and the first contact with the
with the treatment independently evaluated the HFBT at D1, D2, D3,
mucosa measured to the nearest 0.5 mm using a manual probe
D4, and D5 and the VFBL on 10 CBCT images. The inter-examiner
(PCPUN156, Hu-Friedy, Chicago).
reliability of the measurements is shown in Table 1. Subsequently, all
hard tissue dimensions were measured by only one clinician (Hui
In this study, the midfacial mucosa level was considered the Zhao) who had not participated in any related therapy process.
primary outcome variable. To ensure the reliability of the soft
tissue dimension measurements, two calibrated examiners (Hui Li
and Liyan Lin) who were not involved with the treatment indepen-
2.7.4 | Pink aesthetic score
dently evaluated the papilla and midfacial mucosa levels for 10 sub-
jects. The inter-examiner reliability of the measurements is shown The PAS proposed by Furhauser et al13 was chosen as the criterion

in Table 1. Subsequently, all soft tissue dimensions were recorded for determining the soft tissue aesthetic outcome of the implant site

by only one clinician (Hui Li) who had not participated in any at T4. The PAS includes seven variables: the mesial papilla, distal

related therapy process. papilla, midfacial level, midfacial contour, alveolar process deficiency,
soft tissue color and soft tissue texture. Each variable was evaluated
with a 0-1-2 score, with 2 being the best and 0 being the worst.
Thus, the highest total score was 14. The mesial and distal papillae
TABLE 1 Inter-examiner reliability of different parameters were assessed for completeness. All other variables were evaluated
Paired Pearson's by comparison with the contralateral tooth. The threshold of an
samples correlation acceptable PAS was 8. Scores of 12 or more indicated a nearly per-
Parameter t-test coefficient
fect outcome.
Papilla levels (mm) (n = 10) NS 0.991 (P < .001) Before the evaluation, two clinicians (Hanqing Liu and Haihui Li)
Midfacial mucosa level (mm) (n = 10) NS 0.993 (P < .001) were trained and calibrated by 10 cases of single implantation in the
HFBT and VFBT (mm) (n = 10) NS 0.992 (P < .001) anterior maxilla. The inter-examiner reliability of the measurements is
PAS (n = 10) NS 0.995 (P < .001) shown in Table 1. All of the PAS evaluations were completed by one

Abbreviations: HFBT, horizontal facial bone thickness; NS, non-significant; clinician (Hanqing Liu) who had not participated in any related therapy
PAS, pink aesthetic scores; VFBT, vertical facial bone level. process.
6 LIU ET AL.

F I G U R E 3 The facial bone for all 45 implants was measured post-operatively (T1) and 12 months after the implant surgery (T4) by sagittal
cone beam computed tomography (CBCT) (i-CAT 17-19, Imaging Sciences International, LLC, Pennsylvania) images through the implant axis.
Five sites (D1, D2, D3, D4, and D5) located at an interval of 1/4 the length of the implant axis (from shoulder to root apex). Lines perpendicular
to the long axis of the implant were made at each site. The horizontal facial bone thickness (HFBT) was defined as the distance from the facial
outline of the implant to the outer surface of the facial bone on these lines. The vertical facial bone level (VFBL) was defined as perpendicular
to the distance from the shoulder of the implant platform to the most coronal point of the facial bone. This distance was parallel to the axis
of the implant

TABLE 2 Tooth types and reasons

Reasons for failure
Tooth types for failure
Fracture Caries/endodontic Periodontal Root resorption Total
Central incisors 7 9 3 4 23
Lateral incisors 4 4 5 3 16
Canines 0 3 2 1 6
Total 11 16 10 8 45

2.7.5 | VAS evaluation of patient aesthetic
satisfaction
Patient aesthetic satisfaction was measured with a VAS at T3. The
patients were asked to describe their aesthetic satisfaction using a
10-cm VAS, with “not at all satisfied” at the left end and “completely
satisfied” at the right end. A clinician (Hui Zhao) unrelated to this
study asked each subject the following question: “How would you
rate the aesthetic satisfaction of this treatment?”
2.8 | Data analysis
Each subject was evaluated as an experimental unit during the data
analysis process. Each parameter is presented as the mean and
SD. The changes over time in these variables were examined by
repeated-measures one-way analysis of variance (ANOVA). The thick-
ness of facial bone at T1 and T4 at each measurement level were
compared using the paired t test. Correlations among the HFBT
change at D1, the VFBL change, the initial (T1) HFBT at D1, and the
initial (T1) VFBL were analyzed. The level of significance was set at
α = .05. All analyses were performed using SPSS (Version 24.0, SPSS
Inc.; IBM Corporation, Chicago, IL).
3 | RESULTS
Of the 75 patients in this study, 49 fulfilled the criteria and accepted
single-tooth replacement in the aesthetic zone by means of immediate
implant placement from May 2014 to May 2017. As 4 patients were
lost to follow-up after permanent restoration (T3) because they
moved to work elsewhere, 45 patients completed the follow-up
examination at T4. The mean age of the 45 patients (24 women,
21 men) was 36.7 years (range, 18-52). The type and cause of tooth
failure are shown in Table 2. The most common site of the failing
tooth was the central incisor, and the most prevalent cause was car-
ies. A total of 45 two-piece tapered implants were inserted
(Dentium: diameter = 3.6 mm, length = 10 mm, eight implants; diam-
eter = 3.6 mm, length = 12 mm, 18 implants; diameter = 3.6 mm,
LIU ET AL. 7

length = 14 mm, 10 implants; diameter = 4.0 mm, length = 10 mm,
two implants; diameter = 4.0 mm, length = 12 mm, four implants;
and diameter = 4.0 mm, length = 14 mm, three implants). The pri-
mary stability of all implants included in this study was greater
than 35 N m.
3.1 | Implant survival and complications
According to the criteria for successful osseointegration suggested by
Buser et al,11 all 45 implants stayed in the original site, resulting in a
100% cumulative implant survival rate at 1 year post-operatively. Dur-
ing this observation period, there were no major biologic or prostho-
dontic complications as determined by a clinical examination at each
the hard tissue data analysis, the CBCT images revealed that no VFBL
was negative at T4.
3.2 | Soft tissue parameters
Twenty-eight of 45 patients (62.2%) in this study achieved good
primary wound closure. There were five cases (11.1%) of poor early
wound healing, including three of massive exudation and two of
pyogenic infection. After antibiotic treatment, healing was achieved in
all cases within 1 month after the operation.
Table 3 shows the soft tissue parameters around the implant site.
During the study period, plaque scores remained low (<20%). How-
ever, in 80% of the subjects, there was a maximum plaque score of
25%. Approximately half of the sites showed bleeding on probing.

follow-up visit. Complications of soft tissue healing occurred in five During the period of observation, the probing depth was reduced
from 4.00 (T2) to 3.56 (T4) mm. Other parameters showed no signifi-
cases after the surgery, which will be discussed in detail below. During
cant differences over time.
Table 4 depicts the soft tissue dimensions around the implant res-
TABLE 3 Peri-implant clinical conditions at different time torations compared with those before failing tooth extraction. At T3,
intervals the largest reductions in papillary height were observed, namely, a
Parameter T2 T3 T4 mean loss of 0.55 mm (P = .007) for mesial papillae and 0.50 mm

Plaque score (%) 17 ± 23 19 ± 21 18 ± 19

(P = .012) for distal papillae. Although the papillary height showed no
significant differences at each follow-up, the papillary height at T4
Probing depth (mm) 4.00 ± 0.82 3.73 ± 0.74 3.56 ± 0.68
indicated some recovery compared with T3, namely, 0.45 mm
Bleeding on probing (%) 52 ± 25 49 ± 23 45 ± 19
(P = .019) at the mesial side of the implant site and 0.42 mm (P = .023)
Note: T2 = 1 month post operation; T3 = 6 months post operation; at the distal side. Over time, the midfacial gingival margin continued
T4 = 12 months post operation; Mean ± SD.
to decline. The largest recession of the midfacial peri-implant mucosa
level was observed at T4, with a mean loss of 0.59 mm (P = .003).
T A B L E 4 Changes in soft tissue dimensions compare with the At each follow-up timepoint, the midfacial soft tissue level showed no
pre-operative status significant change.
Parameter T2 T3 T4
Mesial papilla level (mm) −0.49 ± 0.89a −0.64 ± 0.79a −0.45 ± 0.75a 3.2.1 | Hard tissue parameters
Distal papilla level (mm) −0.47 ± 0.79a −0.50 ± 0.85a −0.42 ± 0.75a
Six implants (13.3%) were excluded from the hard tissue data analysis;
Midfacial mucosa −0.51 ± 0.91a −0.55 ± 0.85a −0.59 ± 0.71a
level (mm) in two cases (4.4%), the CBCT image was unclear, and in four cases
(8.9%), some of the measurement sites showed no facial bone plate.
Note: T2 = 1 month post operation; T3 = 6 months post operation;
A total of 39 implants were included in the statistical analysis.
T4 = 12 months post operation; Mean ± SD.
a
Significant soft tissue loss in comparison to the pre-operative The mean and SD of the facial bone dimensions at different
status: P < .05. time intervals and measurement sites are presented in Table 5. From

T A B L E 5 Comparison of facial bone

Facial bone dimension (mm)
dimensions at different time Parameter Dimensional change (mm)
follow-up (n = 39) T1 T4 P (T1 vs T2)a T4-T1
HFBT (D1) 3.25 ± 1.37 2.31 ± 1.13 <.001 −0.94 ± 0.51
HFBT (D2) 3.35 ± 1.21 2.55 ± 0.89 <.001 −0.80 ± 0.42
HFBT (D3) 3.30 ± 0.98 2.45 ± 0.91 <.001 −0.85 ± 0.37
HFBT (D4) 2.98 ± 0.99 2.16 ± 1.29 <.001 −0.82 ± 0.51
HFBT (D5) 2.33 ± 0.79 1.88 ± 0.72 <.001 −0.45 ± 0.21
VFBL 0.96 ± 0.51 0.55 ± 0.21 <.001 −0.41 ± 0.21

Note: T1 = immediately after implant surgery; T4 = one year after implant surgery; Mean ± SD.
Abbreviations: HFBT, horizontal facial bone thickness; VFBT, vertical facial bone level.
a
Paired t test, the level of significance was set at α = .05.
8 LIU ET AL.
TABLE 6 Pink aesthetic scores (PAS) conditions at 1 year
follow-up
Parameter 0 1
Mesial papilla 3 12
Distal papilla 6 14
Midfacial level 4 16
Midfacial contour 6 16
Alveolar process deficiency 9 15
Soft tissue color 2 10
Soft tissue texture 2 7
T1 to T4, significant reductions in the VFBL and HFBT were observed
at each measurement site (D1-D5) (P < .001). At each of the mea-
surement sites (D1, D2, D3, D4, and D5), the HFBT showed a signifi-
cant difference at T1 and T4 (P < .001). The mean HFBT change at
D1, D2, D3, D4, and D5 was −0.94 ± 0.51 mm, −0.80 ± 0.42 mm,
−0.85 ± 0.37 mm, −0.82 ± 0.51 mm, and −0.45 ± 0.21 mm, respectively.
The HFBT changes at D2, D3, and D4 were similar, but they were signifi-
cantly lower than that at D1 and significantly greater than that at D5.
The mean VFBL change was −0.41 ± 0.21 mm (P < .001). All the
VFBL values were positive at T1 and T4.
There were no significant correlations among the HFBT change at
D1, VFBL change, initial (T1) HFBT at D1, and initial (T1) VFBL.
3.2.2 | Pink aesthetic score
The outcome of all seven variables of the PAS is shown in Table 6.
The soft tissue texture was the most satisfactory, reflecting a perfect
condition compared with the contralateral tooth in 36/45 (80%) cases.
The most unfavorable result was alveolar process deficiency, which
was indicated in 9/45 cases (20%). The mean PAS was 10.58
(SD, 2.47), and the PAS ranged from 5 to 14. Eighty of 45 cases (40%)
reflected an (almost) perfect outcome (PAS ≥ 12), and 4/45 cases (9%)
showed an unfavorable result (PAS < 8).
3.2.3 | VAS evaluation of patient aesthetic
satisfaction
The patient aesthetic satisfaction evaluated by a VAS reflected a
mean score of 87.9% (range, 75% to 100%).
4 | DISCUSSION
For patients with a single failing tooth in the anterior maxillary region
with indications for extraction and a labial bone wall defect, scholars
often select early implant placement (type 2) combined with flap sur-
7
gery, GBR and submerged healing after soft tissue healing. For these
patients, the authors adopted immediate implantation and obtained
acceptable therapeutic outcomes. The timing and method of opera-
tion in this study are different from those in previous studies. Using
the method proposed in this study, tooth extraction, implant insertion,
GBR and soft tissue plasty could be completed in only one operation.
The approach reduces the number of operations and shortens the
2 treatment cycle. At T4, the implant survival rate was 100%, indicating
that immediate implantation did not affect the implant survival rate in
30
the subjects in this study. In fact, sufficient primary stability is the key
25
to immediate implantation success.14
25
In recent years, many studies have shown that the clinical out-
23
comes of non-submerged healing in immediate implant placement are
21
widely recognized.15,16 For implantation with GBR, whether delayed
33 or immediate, submerged healing is selected in almost all of cases to
36 avoid bone graft material exposure and reduce the influence of the
external environment. However, 45 patients in this study were
treated with GBR with non-submerged healing, and at T4, the implant
survival rate was 100%.
Previous studies have shown that poor wound healing is five
times more frequent in immediate implantation than in delayed
implantation in the anterior maxillary region.17 When immediate
implantation combined with GBR is used, the incidence of poor
wound healing may be higher, especially regarding exudation. To
prevent exudation after GBR, local pressure and dexamethasone
were used in this study. The incidence of poor wound healing was
11.1%; this value is 15% lower than that reported by Tonetti17
(26.1%), who used type 1 placement combined with GBR. The pri-
mary wound closure rate in this study was 62.2%, which is similar
to that reported by Tonetti17 (61.7%). Although there were five
cases of negative primary wound closure in this study, the implant
survival rate was not affected.
In this study, the plaque levels remained low (<20%), but more
than 40% of the sites bled on probing. Previous studies have shown a
similar phenomenon.18-20 At T4, the probing depth was relatively high
(3.56 mm); another study reported similar results with the use of two-
piece implants.21
In this study, significant reductions in the papillary height were
observed at T3 (6 months post-operatively), namely, 0.55 mm
(P = .007) for mesial papillae and 0.50 mm (P = .012) for distal papil-
lae. These results seem greater than those of the previous study
reported by Rouck et al,22 who performed immediate single-tooth
implantation in the anterior maxilla. They reported a mean loss of
0.50 mm for mesial papillae and 0.41 mm for distal papillae at
6 months post-operatively.22 In a recent study, Arora and Ivanovski
reported that a mean loss of papillary height of 0.82 mm for mesial
papillae and 0.79 mm for distal papillae at the time of definitive
crown placement,23 and they used a method similar to that
reported by Rouck et al. In this study, an increase in papillary height
occurred between T3 and T4. This phenomenon has been previ-
ously reported to occur during the first year of function of single-
tooth implant restorations.24
In a previous study, Chen & Buser found an increased risk of
advanced midfacial recession in immediate implantation.10 For
patients with a single failing tooth in the anterior maxillary region with
indication for extraction and a labial bone wall defect, the main reason
why scholars do not recommend immediate implantation therapy is
the high risk of aesthetic complications, especially midfacial recession.
LIU ET AL.
In this study, midfacial soft tissue recession was the primary observed
index. Significant midfacial soft tissue recession was observed at T4
(0.59 mm); this extent of recession is greater than that reported by
25
Rouck et al, who performed immediate single-tooth implantation in
the anterior maxilla (0.55 mm), and lower than that reported by Cor-
26
nelini et al (0.75 mm). Compared with the midfacial soft tissue
recession reported in a study on inserting a single implant in a healed
site Cardaropoli et al,26 the midfacial soft tissue recession in this study
after the first year of function was similar, at approximately 0.6 mm.
In a recent study, Arora and Ivanovski reported a midfacial soft tissue
recession of 0.26 mm in the immediate placement group (type 1) and
0.39 mm in the early placement group (type 2) after 1 year.23 How-
ever, they applied standardization based on photographs combined
with digital analysis, which is different from the method applied in
this study. Regarding the VFBL resorption at T4, the midfacial soft
tissue recession measurements were greater than those determined
by CBCT.
In the hard tissue evaluation, four out of 45 implant CBCT
images (8.9%) showed that the facial bone was too thin or invisible,
which was more frequent than in Buser's study27 in the aesthetic
area (4.9%). From T1 to T4, the most obvious HFBT change was
observed at D1 (P < .001). The HFBT change at D1 was 1.40 mm
(28.9%), and the VFBT change was 1.15 mm (42.7%). Previous
studies have shown different bone dimension changes at similar
sites (implant coronal platform). In a clinical study of immediate
implantation and simultaneous GBR in the maxillary anterior
region, Degidi et al found a horizontal facial bone resorption of
0.88 mm (29.3%) and a vertical facial bone resorption of 0.76 mm
(25.6%) at the one-year follow-up, as determined by CBCT.28 Roe
et al used a similar method and found a horizontal facial bone
resorption of 1.23 mm (49.0%) and a vertical bone resorption of
29
0.82 mm (86.3%). From T1 to T4, the HFBT changes at D1, D2,
D3, and D4 were higher than those at D5, which is similar to the
results reported by Roe et al. 29
In this study, there was no significant correlation between the
initial (T1) HFBT at D1 and the VFBT change. This is consistent
with the results 1 year after immediate implantation in the maxil-
30 29
lary area with GBR reported by Taichiro et al and Roe et al.
a clinical study of the bone thickness at the coronal platform of
more than 3000 implants placed without simultaneous bone
grafting, Spray et al31 found that when the initial facial bone thick-
ness of the implant coronal platform was 1.3 to 1.8 mm, the thin-
ner the initial bone was, the more vertical bone absorption
occurred. When the initial bone thickness was 1.8 to 2.0 mm, the
vertical bone absorption decreased significantly in that study.
Similarly, Kaminaka et al32 reported that vertical bone resorption
at the labial side of the implant was negatively correlated with
the initial bone thickness at the coronal platform of the implant.
In their study, the thickness of the facial bone of the implant was
less than 1.8 mm.
At the one-year follow-up, the PAS of the 45 subjects was accept-
able (PAS: 10.58 ± 2.47; range, 5-14). This result is relatively higher
and lower than recent results of immediate implant placement after
9
1 year reported by Vidigal et al33 (PAS: 8.63 ± 2.40) and Cosyn et al34
(PAS: 12.15 ± 0.99), respectively. The threshold of an acceptable PAS
was 8, as proposed by Pieri et al.35 In this study, four out of 45 cases
(9%) showed an unfavorable result (PAS < 8), which is similar to
the results of previous studies 36,37 over a short time span (range,
0% to 11%). On the other hand, 18 of 45 cases (40%) reflected an
(almost) perfect outcome (PAS ≥ 12), which is slightly higher than
previous findings36,37 (range, 26% to 39%). Several studies have
shown that the PAS increases over time after the 1-year follow-
up.4,38 The authors will evaluate the PAS at the 3-year follow-up
in the future.
The limitations of this study are as follows. CBCT artifacts
around the implant are unavoidable. Currently, there are no effec-
tive methods for reducing peri-implant artifacts on CBCT images,
which increase measurement error. The bone thickness around
implants needs greater than 0.5 mm to be clearly imaged.39,40 Thus,
in some cases of CBCT images showing no facial bone plates, facial
bone plates may actually be present. For soft tissue measurements,
recent studies have used digital analysis. Thus, the outcomes of the
manual measurement methods applied in this study may be differ-
ent from those obtained digitally. While the white aesthetic score
is an index for evaluating the restorative materials and method, it is
not discussed here. This study focuses on the soft and hard tissue
response achieved by the proposed surgical procedure. In this
study, the follow-up duration was short, and reconstruction of the
soft and hard tissues was not completed. The authors will continue
to follow the soft and hard tissue changes of the patients in this
study for 3 years after the operation.
5 | C O N CL U S I O N
At the one-year follow-up, immediate implant placement combined
with flap surgery, GBR and non-submerged healing for single ante-
rior maxillary teeth with a facial bone defect was determined to be
a valuable treatment, as assessed by preliminary clinical outcomes.
The long-term hard and soft tissue changes still require further
observation.
In
ACKNOWLEDG MENTS
In this study, Yang Zhen is the co-first author with Liu Renzhang. This
study was supported by the Qingdao Municipal Science and Technol-
ogy Bureau (No. 15-9-2-73-nsh).
CONFLIC T OF INT ER E ST
The authors disclose that they have no conflict of interest related to
this study.
OR CID
Renzhang Liu https://orcid.org/0000-0002-3093-2015
10
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