IMMEDIATE IMPLANTS

1
CONTENTS

I. Introduction
II. Aims of therapy
III. Diagnosis and treatment planning
IV. Criteria for case selection
V. The rule of 5 triangles to decision-making process
VI. Advantages
VII. Disadvantages
VIII. Indications
IX. Contraindications
X. Classifications of immediate implant placement (IIP)
XI. Tooth extraction and implant placement procedures
XII. The bony gap
XIII.Factors influencing the outcome of IIP
XIV.Soft tissue management of immediate implants
2
CONTENTS

XV. IIP in infected sockets

XVI.IIP in periapical infections

XVII.Histological outcomes
1. Changes inside the alveolar socket
2. Dimensional alterations of the alveolar bone crest
3. Influence of implant
4. Influence of socket anatomy
5. Influence of surgical protocol
6. Morphogenesis of peri-implant mucosa
7. Immediate implant placement (IIP) vs. spontaneous
healing of the socket 3
XVIII.Clinical outcomes
A. Survival rates

B. Hard-tissue changes

C. Interproximal hard-tissue changes

D. Soft tissue healing/esthetic outcomes

E. Interdental papillae

F. Biological complications

XIX.Recommendations for clinical practice

XX. References
4
I. INTRODUCTION

5
  Missing teeth and supporting oral tissues have traditionally
been replaced with dentures or bridges permitting restoration
of chewing function, speech, and aesthetics.
 Dental implants offer an alternative. They are inserted into the
jawbones to support a dental prosthesis and are retained
because of the intimacy of bone growth on to their surface.
 This direct structural and functional connection between living
bone and implant surface, termed Osseointegration, was first
described by Brånemark 1977 and has undoubtedly been one
of the most significant scientific breakthroughs in dentistry
over the past 40 years.

Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate-
delayed and delayed implants) (Review). Copyright © 2010 The Cochrane Collaboration. Published by John Wiley 6
& Sons, Ltd.
  Teeth may have been lost through dental disease or trauma or
they may be congenitally absent. However in many clinical
situations compromised teeth or roots may still be present in
the patient’s mouth.

 Traditionally, before placing dental implants, compromised

teeth were removed and the extraction sockets were left to heal
between several months and 1 year.

 Original protocols required the placement of implants into

healed edentulous ridges. Branemark 1977; Adell 1981.

Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate-delayed
and delayed implants) (Review). Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. 7
Periodontol 2000 2008; 47:79-89.
 BRANEMARK’S ORIGINAL PROTOCOL

6 To 8 Months Healing Post-

Extraction

Placing Machined Titanium

Implants In a 2-stage Approach

3 To 6 Months Stress Free Healing

Period For Osseointegration To
Occur

The entire treatment time would

be 1 year or longer…
8
 The Negatives Of Delayed Implant Placement

Volume loss of alveolar bone

 Increased time of edentulism
 Longer treatment time
 Additional surgical procedure
 Psychological impact on the patient

9
  Immediate implant placement after tooth extraction has
become a common surgical protocol in clinical practice. This
therapeutic concept was introduced in Scheult & Heimke
1976 as an alternative protocol to the classical delayed implant
surgical protocol proposed by Branemark.

 In 1989, Lazzara placed implants at the time of tooth

extraction.

Vignoletti and Sanz. Immediate implants at fresh extraction sockets: from myth to reality. Periodontol 2000
2014;66:133-52.
Branemark PI. Osseointegration and its experimental background. J Prosthet Dent 1983:50:399–410. 10
Schulte W, Heimke G. The Tubinger immediate implant. Quintessenz 1976: 27: 17–23.
 In the 1990s, these protocols were modified to include implant
placement in fresh extraction sockets [Schwartz-Arad and
Chaushu 1997; Mayfield 1999] or in partially healed alveolar
ridges [Nir-Hadar et al 1998] predominantly for implants in
the esthetic zone.

 However, the great majority of patients are interested in

shortening the treatment time between tooth extraction and
implant placement, or even better in having the implants
inserted during the same session as the teeth are extracted.

Chen et al. Esthetic Outcomes Following Immediate and Early Implant Placement in the Anterior Maxilla—A
Systematic Review Int J Oral Maxillofac Implants 2014;29(Suppl):186–215.
Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome.
11
Periodontol 2000 2008; 47:79-89.
 Currently, implants are also being placed in

(1) fresh extraction sockets,

(2) Infected sockets,

(3) periapical infected sites,

(4) the area of the maxillary sinus, etc.

12
Hammerle et al. Timing of implant placement. Lindhe J. 5th ed
II. AIMS OF THERAPY

13
 During the surgical phase of therapy, ideal conditions must be
established for successful bone and soft tissue integration to
the implant.

 In a growing number of cases, however, treatment must also

satisfy demands regarding the esthetic outcome. In such cases,
the overall surgical and prosthetic treatment protocol may
become more demanding, since factors other than
osseointegration and soft tissue integration may play an
important role.
14
Hammerle et al. Timing of implant placement. Lindhe J. 5th ed
Restoration of Esthetic
health and importance and
function tissue biotype

Esthetic and
Location non-esthetic
zones

Flat-thick/the
Volume of
pronounced
available hard
scalloped thin
and soft tissues
biotype
15
Hammerle et al. Timing of implant placement. Lindhe J. 5th ed
 Restoration of health and function
 In cases where the restoration of health and function
constitutes the primary goal of the treatment, the location and
volume of available hard and soft tissues are the important
factors to consider.

 The replacement of a single-rooted tooth with an implant in a

fully healed ridge will, in most cases, ensure proper primary
stability with the implant in a correct position.

16
 Also, the soft tissues are sufficient in volume and area.

 The mucosal flap can be adapted to the neck (or the healing cap)
of the implant (one-stage protocol).

 When primary wound closure is intended (two-stage protocol),

mobilization of the soft tissue will allow tension-free
adaptation and connection of the flap margins.

17
 When an implant is placed in the fully healed site of a multi-rooted
tooth, the surgical procedure becomes more demanding.

 Often the ideal position for the implant is in the area of the inter-
radicular septum.

 If the septa are delicate, anchorage for primary implant stability may
become difficult to achieve.

 In molar sites, there is often only a small amount of soft tissue

present. This may create a problem with respect to wound closure
with a mobilized, tension-free flap.

 In some molar sites, primary wound closure may not be possible at

times following implant installation. 18
 The presence of marginal defects (gaps) between the implant
and the fully healed ridge following type 4 placement 
significant problem that could compromise osseointegration.

 In such a horizontal marginal defect (gap) of ≤2 mm, new bone

formation as well as defect resolution and osseointegration
of the implant (with a rough titanium surface) will occur.

[Wilson et al. 1998; Botticelli et al. 2004; Cornelini et al.

2005].

19
 Esthetic importance and tissue biotype
 The replacement of missing teeth with implants in the esthetic zone
is a demanding procedure. Deficiencies in the bone architecture
and in the soft tissue volume and architecture may compromise the
esthetic outcome of treatment (Grunder 2000).

 Botticelli et al. 2004  Placed implants in fresh extraction sockets.

During healing, the implants became clinically osseointegrated within
the borders of the previous extraction socket. However, significant loss
of buccal bone height (contour) also occurred. In esthetically critical
situations, this loss of contour may lead to a compromised
outcome. Hence not infrequently, tissue augmentation procedures
must be performed in the esthetic zone.
20
 Also, when a two-stage implant placement protocol is used, the
labial mucosa will recede following abutment connection
surgery (Mean values - 0.5 - 1.5 mm). These findings
additionally stress the necessity for a careful treatment approach
when implants are placed in the esthetic zone.

 The biotype of the soft and hard tissue tissues may play a role
regarding the esthetic outcome of implant therapy. The scalloped
thin biotype is associated with a delicate bone housing.

 Evans and Chen 2007  Buccal tissue recession at single-

tooth implants was more pronounced in patients exhibiting a
thin biotype compared to patients with a thick biotype.
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III. DIAGNOSIS AND TREATMENT
PLANNING

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 In general, immediate dental implant selection criteria are
contextually dependent on the unique circumstances that pertain
to each individual patient and should reflect the following
factors:

i. Thorough medical and dental histories,

ii. Clinical photographs,

iii. Study casts,

iv. Periapical and panoramic radiographs,

v. Linear tomography/computerized tomography/CBCT of the

proposed implant sites.
Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for 23
successful outcome. Periodontol 2000 2008; 47:79-89.
vi. Determining the overall vs. individual prognosis.
vii. Reasons for tooth extraction [Becker et al 2000]
a. Insufficient crown to root ratio,
b. Remaining root length,
c. Periodontal attachment level,
d. Furcation involvement,
e. Periodontal health status of teeth adjacent to the proposed
implant site,
f. Non-restorable caries lesions,
g. Root fractures with large endodontic posts,
h. Root resorption,

Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for 24
successful outcome. Periodontol 2000 2008; 47:79-89.
 i. Root perforation,

j. Periapical pathology,

k. Questionable teeth in need of endodontic retreatment.

l. Implants to replace teeth with nonvital pulp, fractured at

the gingival margin with roots shorter than 13 mm, is
often considered the treatment of choice [Lovdahl
1992].

Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for 25
successful outcome. Periodontol 2000 2008; 47:79-89.
 viii. In esthetic zone 
 The scalloping of the periodontium,
 Level of crestal and interproximal bone,
 Smile line, and
 Morphology of the gingival tissues.
[Ochsenbein 1969; Becker et al
1997;Kan et al 2003; Kois 2004]
 Proposed inter-implant distance,
 Existing contact relationships and
interproximal bone.

[Tarnow et al 1992, 2003]

Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for 26
successful outcome. Periodontol 2000 2008; 47:79-89.
  Radiographic examination 
a. Available bone
b. Bone shape,
c. Bone quality,
d. Bone quantity,
e. Bone width,
f. Bone height.

 A minimum of 4–5 mm of bone width at the alveolar crest,

and at least 10 mm bone length from the alveolar crest to a
safe distance above the closest anatomical structure are
recommended [Worthington 2004].
Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for 27
successful outcome. Periodontol 2000 2008; 47:79-89.
 In some patients, there may be a thin ridge of bone at the crest
that will project onto the panoramic film but which in practice
may be “useless” for implant accommodation unless a bone
augmentation procedure is used.

 This crestal ridge of relatively useless bone must be taken into

account. The magnification factor of an individual panoramic
machine must be known and factored into the calculation of
the permissible implant length.

Philip Worthington. Injury to the inferior alveolar nerve during implant placement: A formula for 28
protection of the patient and the clinician. Int J Oral Maxillofac Implants 2004;19:731-34.
  “Safety zone”  A small space
between the tip of the implant (or the
preceding drill) and the anatomical
landmark.
 If H is the height of bone apparently
available above the anatomical
landmark on the panoramic film,
 c is the height of “useless” bone at the
crest,
 s is the safety zone (for this example, a
safety zone of 2 mm will be used),
 m is the magnification factor (eg, if
there is 25% magnification, m would
be 5⁄4), and
 L is the permissible implant length,
Philip Worthington. Injury to the inferior alveolar nerve during implant
29
placement: A formula for protection of the patient and the clinician. Int J Oral
Maxillofac Implants 2004;19:731-34.
 L = (H/M) – c – s .
 For example,
if H = 15 mm measured
on a panoramic
radiograph,
c = 2 mm,
s = 2 mm, and
m = 5/4, then L = 8 mm
(Implant length).
if c = 0, then L = 10 mm.

Philip Worthington. Injury to the inferior alveolar nerve during implant placement: A formula for 30
protection of the patient and the clinician. Int J Oral Maxillofac Implants 2004;19:731-34.
  A satisfactory esthetic result in the esthetic zone requires the
interproximal bone height to be 5 mm or less, when
measured from the contact point of the adjacent tooth. As the
distance from the contact point to the interproximal bone
increases, the likelihood of retention of the interproximal
papillae after implant placement diminishes.

 Patients must be made aware of potential esthetic shortcomings

if implants are placed in compromised esthetic zones.

Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for 32
successful outcome. Periodontol 2000 2008; 47:79-89.
  Once a patient is considered a candidate for immediate
implant, a surgical guide may be used to assure proper implant
placement.

 A provisional appliance with an ovate pontic for insertion

after implant placement [Johnson and Leary 1992; Dylina
1999; Zitzmann et al 2002].

Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for 33
successful outcome. Periodontol 2000 2008; 47:79-89.
IV. CRITERIAS FOR CASE SELECTION

34
McNutt MD, Chou CH. Current Trends in Immediate Osseous Dental Implant
Case Selection Criteria. Journal of Dental Education 2003;67[8]:850-9. 1. Achieving predictable
Osseointegration: Primary
Stability.

2. Achieving predictable
Osseointegration: Bone Quality
and Bone Quantity.

3. Anatomical site considerations:

A. Extraction site morphology.
B. Surrounding Anatomy. 35
Ajay Kumar. Criteria for immediate placement of oral implants – a mini

4. Maximizing Esthetic results and soft

tissue maintenance
review . Biology and Medicine 2012;4(4): 188–192

5. The surgical technique

6. Presence of infection and pathology

7. Implant component selection for

immediate implant
36
 V. THE RULE OF 5 TRIANGLES TO
DECISION-MAKING PROCESS

http://www.eao.org/new-protocol-immediate-implants-rule-5-triangles-case-report-pages-4-5-
0#sthash.MVa02QQH
Gracia et al 2014.
37
 There are 5 key aspects to follow in placing an immediate implant
in order to reach favorable outcomes, these are the 5 triangles 

3. Jumping
1. Primary
distance (Filling of
stability where 2. The presence of
the gap between
there is existing buccal plate
buccal plate and
apical bone
implant)

4. Tissue biotype 5. Implant design.

38
 1. Primary stability where there is existing apical bone

• Placing an immediate
implant requires sufficient
bone apical to the
extracted socket.
• An approximate 2-4 mm of
bone apical to the alveolus
is necessary in order to
have a greater possibility of
obtaining a stable anchor,
and thus obtain stability.
• This can be enhanced by the
type of implant used, which
is of a tapered design.

39
 2. The presence of buccal plate

• In a multi-center study of 2667

implants, minimal bone loss was
shown in sites with more than
1.8-2.0 mm of facial bone [Spray
et al 2000]. This implied that
buccal bone thickness is
important in predicting the
resorption of the buccal plate.

• The buccal bone is a critical

aspect, and the first triangle, in
order to prevent esthetic
complications [Park 2010].

40
• Presence of a 2 mm buccal plate is crucial to avoid soft tissue
recession. [Grunder et al 2005; Juodzbalys et al 2008].

 A horizontal buccal bone width of at least 2 mm should remain at the

end of the resorption phase, allowing for the conical peri-implant
bone resorption to remain inside the width of the bone wall.

[Spray et al 2000;Grunder et al 2005]

 Sites with IIP were found to have marked apical displacement of the
buccal plate with no vertical bone loss in the lingual aspect
[Vignoletti et al 2009].

 The mean vertical differences between buccal and lingual alveolar

crest was approx. 1 mm [Vignoletti et al 2012].
41
3. Jumping distance (Filling of the gap between buccal plate and
implant)/Horizontal Defect Dimension

Close adaptation of
the implant to the
socket wall
promotes greater
osseointegration.
 • When immediate implants
are placed, peri-implant
voids are frequently present
due to a gap between the
alveolar socket and the
implant.
• Resorption prevails during
healing when the gap is
large and the biotype is
thin.
[Araujo et al 2006; Tomasi et
al 2010].

Capelli et al. Implant-Buccal plate distance as a

diagnostic parameter: A prospective Cohort Study
on implant placement in fresh extraction sockets. J
43
Periodontol 2013;84[12]:1768-74.
 In order to compensate for the expected horizontal bone
resorption of the buccal plate, the use of bone substitutes, with a
low resorption rate, to fill the gap has been shown to reduce this
resorption significantly and therefore their use should be
advocated when the esthetic demands are high.

Vignoletti and Sanz. Immediate implants at fresh extraction sockets: from myth 44
to reality. Periodontol 2000 2014;66:133-52.
 Araújo et al 2011 Filling the gap with deproteinized bone
mineral has beneficial outcomes:
(i) Hard tissue healing process is modified,
(ii) Additional hard tissue is present at the re entrance of the
socket after a period of bone healing,
(iii) Soft tissue recession is prevented, and
(iv) There is an improvement of the marginal bone-to-implant
contact.

Araújo MG, Linder E, Lindhe J. Bio-Oss collagen in the buccal gap at immediate implants: a 6- 45
month study in the dog. Clin Oral Implants Res 2011;22(1):1-8.
 In the intact socket , a
critical component of the
peri implant defect is the
size of the horizontal defect
(HD) .

 Implants with a HD of
<2mm 
spontaneous healing &
osseointegration takes
place, if implant has
rough surface.

 If HD >2 mm  to
achieve bone healing,
bone fill, likely by using
collagen barrier
membrane & implants
with a sand blasted &
acid etched surface.
46
WHEN TO CONSIDER GRAFTING PROCEDURES?
 If any osseous defect exists circumferentially.

 If there is translucence of implant on labial /buccal bone.

 If there is residual exposure of implant body.

 If dehiscence or fenestration exists.

 If there is primary closure of soft tissue flaps.

 If vertical releasing incision is necessary.

 4. Tissue biotype
The patient´s biotype, is also of
crucial importance, being more
favorable, if it´s thick rather than
thin [Park 2010].

Thin and thick tissue biotypes

were previously defined as < 1.5
mm and > 2 mm tissue thickness
[Claffey and Shanley, 1986].

A thin tissue biotype increased

the risk of mucosal recession
around dental implants
[Chen and Buser 2009; Chen et
al 2009; Evans and Chen 2008;
Kan et al 2011].
Wang et al. using soft tissue graft to prevent mid-facial
mucosal recession following immediate implant placement.
J Int Acad Periodontol 2012;14[3]:76-82 48
 Thin Biotype

• Thin scalloped biotype

(15% prevalent)
• Distinct disparity between
location of gingival margin
facially and interproximally.
• Delicate and friable soft
tissue.
• Small amount of attached
gingiva.
 Thick Biotype

 Thick flat biotype--more

prevalent (85%).

 Adequate amount of attached

gingiva.

 Dense fibrotic soft tissue.

 Ideal for placing implants.

 5. Implant design.

• Different implant designs influence

the biomechanics of the environment
where an immediate implant is
placed.
To enhance primary stability, self-
tapping implants were developed,
which compress the alveolar bone as
the implant is inserted.

51
 VI. ADVANTAGES

Ataullah et al. Implant placement in extraction sockets: a short review of the literature and
presentation of a series of three cases. J Implantol 2008;34[2]:97-106 52
1. Patient acceptability.
2. Reduces the treatment time & interval during the
transitional period.
3. Socket as a guide for determination of parallelism &
alignment to the opposing & adjacent teeth.
4. Surgeon can position the implant more favorably than the
original position.
5. Facilitates final restoration & minimizes need for severely
angled abutments /fabrication of telescopic copings.
6. Implants in extraction sites can be placed in the same
position as the extracted teeth.
7. Maintenance of soft tissue profile.
8. Prevention of bone loss in both vertical and horizontal
directions.

Ataullah et al. Implant placement in extraction sockets: a short review of the literature and 53
presentation of a series of three cases. J Implantol 2008;34[2]:97-106 53
 VII. DISADVANTAGES

Ataullah et al. Implant placement in extraction sockets: a short review of the literature and
presentation of a series of three cases. J Implantol 2008;34[2]:97-106
Bhola et al. Immediate Implant Placement: Clinical Decisions, Advantages, and Disadvantages.
54
Journal of Prosthodontics 2008;17:576–581
1. Technically more demanding procedure.

2. Lack of control on final implant position.

3. Difficulty in obtaining primary stability.

4. More extensive soft tissue manipulation.

5. Site morphology may complicate optimal implant

placement and anchorage.

6. Thin tissue biotype may compromise optimal outcome.

7. Potential lack of keratinized mucosa for flap adaptation.

8. Added cost of bone grafting.

55
VIII. INDICATIONS

56
1. Non-restorable deep carious lesions,

2. An endodontically infected tooth,

3. Root fracture (vertical/horizontal),

4. Root resorption,

5. Periodontal infection,

6. Periapical pathology,

7. Root perforation, and

8. Unfavorable crown to root-ratio (not due to periodontal loss).

57
IX. CONTRAINDICATIONS

58
1. Inadequate height or width of bone,

2. Lack of soft tissue,

3. Adverse location of anatomical structures,

4. Proximity of adjacent teeth,

5. Failure to achieve primary stability,

6. Inability to attain a restoratively driven position,

7. Angulation or depth of the implant.

8. Unfavorable extraction site morphology.

59
X. CLASSIFICATIONS OF IMMEDIATE
IMPLANT PLACEMENT

60
 SCHOOL OF THOUGHTS:-
1. WILSON AND WEBER 1993.
61

[Classification of and therapy for areas of deficient bony housing prior to dental implant
placement. Int J Periodont Rest Dent 1993;13:451-9]
IMPLANT
ADVANTAGES DISADVANTAGES
PLACEMENT
IMMEDIATE Same appointment - No additional pre-implant - Membrane exposure. –
as extraction. surgery. – No waiting for Comparatively, increased
socket healing. possibility of infection.

RECENT 30-60 days (4-8 - Less possibility of - An additional pre-

weeks)after membrane exposure. –
extraction. Minimal waiting for socket
healing.
DELAYED Following hard - Allows healing to occur. –
tissue maturation Produces dense bone when
bone graft is used.
MATURE Months to years - Allows implant placement
after extraction when previously not
possible. – Can be used to
enhance bony ridges.
implant surgery.
- Possibility of infection
around membrane.
- An additional pre-
implant surgery.
- Possibility of infection
around membrane.
- An additional pre-
implant surgery.
- Technically difficult.
- Possibility of infection
around membrane.
62
 2. MAYFIELD 1999.
[Proceedings of 3rd European World Workshop in Periodontics]

IMPLANT PLACEMENT
IMMEDIATE Same appointment as extraction (0 weeks).

DELAYED 6 - 10 weeks after extraction.

LATE ≥ 6 months after extraction.

Chen et al. Immediate or Early Placement of Implants Following Tooth Extraction:

Review of Biologic Basis, Clinical Procedures, and Outcomes. INT J ORAL MAXILLOFAC63
IMPLANTS 2004;19:12–25
  Most of the studies reviewed described IIP as part of the same
surgical procedure and immediately following tooth extraction,
EXCEPT 

AUTHORS IMMEDIATE IMPLANT PLACEMENT

GOMEZ-ROMAN et Defined it as occurring between 0 – 7 days
al 1997 following tooth extraction.

SCHROPP et al Defined as Implants placed between 3 – 15 days

2003 (mean 10 days) following tooth extraction.

Chen et al. Immediate or Early Placement of Implants Following Tooth Extraction:

Review of Biologic Basis, Clinical Procedures, and Outcomes. INT J ORAL MAXILLOFAC64
IMPLANTS 2004;19:12–25
 AUTHORS EARLY IMPLANT PLACEMENT

HAMMERLE et al This intervention was defined at a consensus

2004; SANZ et al workshop as “Implant placed following tooth
2011. extraction when the complete soft tissue healing
of the socket (typically 4– 8 weeks after
extraction) has occurred”.

Chen et al. Immediate or Early Placement of Implants Following Tooth Extraction:

Review of Biologic Basis, Clinical Procedures, and Outcomes. INT J ORAL MAXILLOFAC65
IMPLANTS 2004;19:12–25
  The majority of studies that described delayed implant
placement used a delay period of 4 - 8 weeks following
extraction, EXCEPT 
AUTHORS DELAYED IMPLANT PLACEMENT
HAMMERLE and 8 - 14 weeks following tooth extraction.
LANG 2001

ZITZMANN et al Between 6 weeks and 6 months following tooth

1996, 1997 extraction.

GOMEZ-ROMAN et 1 week and 9 months following tooth extraction.

al 1997

Chen et al. Immediate or Early Placement of Implants Following Tooth Extraction:

Review of Biologic Basis, Clinical Procedures, and Outcomes. INT J ORAL MAXILLOFAC66
IMPLANTS 2004;19:12–25
 A.1. BASED ON THE TIMING OF PLACEMENT
OF IMPLANTS IN EXTRACTION SOCKET
[HAMMERLE et al 2004]

Hammerle et al. Consensus Statements and Recommended Clinical Procedures

Regarding the Placement of Implants in Extraction Sockets. Group1 Consensus
Statement. Int J Oral Maxillofac Impl 2004;19:26-28.
Lindhe 5th and 6th Ed. 67
 IMPLANT
ADVANTAGES DISADVANTAGES
PLACEMENT
Type 1 Same surgical - Reduced number of - Site morphology may
[IMMEDIATE] procedure and surgical procedures. complicate the optimal
immediately - Reduced treatment placement and
following time. anchorage.
extraction. - Optimal availability of - Thin tissue biotype
existing bone. may compromise
optimal outcome.
- Potential lack of
keratinized mucosa
for flap adaptation.
- Adjunctive surgical
procedures may be
required.
- Technique sensitive.

68
 Indicated in 
- Cases where Restoration of health and function with respect to
the location and volume of both hard and soft tissues is the
primary goal.

69
 IMPLANT
ADVANTAGES DISADVANTAGES
PLACEMENT
Type 2 Complete soft - Increased soft tissue - Site morphology
[EARLY WITH tissue area and volume may complicate the
SOFT TISSUE coverage of facilitates soft tissue optimal placement
HEALING] the socket; management. and anchorage.
typically 4-8 - Allows resolution of - Increased
weeks. local pathology to be treatment time.
assessed. - Varying amounts of
resorption of the
socket walls.
- Adjunctive surgical
procedures may be
required.
- Technique sensitive.

70
 Indicated in 
- Esthetic zone.
- Compromised buccal plate.
- Resolution of the pathology.
- Soft tissue bulk.
- Pronounced scalloped biotype.

71
 Type 3

IMPLANT
ADVANTAGES DISADVANTAGES
PLACEMENT
Type 3 Substantial - Substantial bone fill of - Increased
[EARLY WITH clinical and/or the socket. treatment time.
PARTIAL radiographic - Mature soft tissue - Varying amounts of
BONE bone fill of the facilitates flap resorption of the
HEALING] socket ; management. socket walls.
typically 12- - Adjunctive surgical
16 weeks. procedures may be
required.

72
 Indicated in 
- Pronounced scalloped biotype.
- Placing the implant in a position that facilitates the prosthetic
phase of the treatment.

73
 Type 4
IMPLANT
ADVANTAGES DISADVANTAGES
PLACEMENT
Type 4 [LATE] Healed site; - Clinically healed - Increased
typically >16 - Mature soft tissue treatment time.
weeks. facilitates flap - Large variation in
management. available bone
volume.
- Adjunctive surgical
procedures may be
required.

74
 Indicated in 
- Completely healed ridge.

75
A.1. BASED ON THE TIMING OF PLACEMENT
OF IMPLANTS IN EXTRACTION SOCKET
[QUIRYNEN et al 2007]

Quirynen et al. How Does the Timing of Implant Placement to Extraction Affect
Outcome? INT J ORAL MAXILLOFAC IMPLANTS 2007;22(SUPPL): 203–223 76
77
A.2. BASED ON THE TIMING OF PLACEMENT
OF IMPLANTS IN EXTRACTION SOCKET
[ESPOSITO et al 2010]

78
IMMEDIATE Any implant placed in a fresh extraction
socket just after tooth extraction.
IMMEDIATE-DELAYED Any implant placed in an extraction socket
within 8 weeks after tooth extraction.

DELAYED Any implant placed at least 2 months (≥ 8

weeks) after tooth
extraction.

Esposito et al. Timing of implant placement after tooth extraction: immediate, immediate-
delayed or delayed implants? A Cochrane systematic review. Eur J Oral Implantol
79
2010;3(3):189–205
 B. 1. BASED ON BUCCAL BONE AND
SOFT TISSUE PROFILE
[FUNATO et al 2007]

Funato el at. Timing, Positioning, and Sequential Staging in Esthetic Implant Therapy:
A Four-Dimensional Perspective. Int J Periodontics Restorative Dent 2007;27:313-23 80
Class 1 Intact buccal bone with thick biotype. “Incisionless”
implant placement without flap reflection is viable.

81
Class 2  Intact buccal bone with a thin, more scalloped gingival biotype.
“Incisionless” implant placement is viable, but in combination with a
connective tissue graft or a subsequent connective tissue graft (Staged).
Class 3  Deficient buccal bone within the alveolar housing and
indicated to have limited and acceptable results with immediate
placement with guided bone regeneration plus connective tissue
graft.
 Depending on the degree
of compromise to the
buccal plate, the case may
alternatively be handled
in a staged approach
using a socket
augmentation
procedure and
subsequent implant
placement.
 In many cases,
particularly with thin
biotypes, this method
provides a more
predictable and safer
outcome.

86
Class 4  Deficient buccal bone deviating from alveolar housing and
implant placement within the remaining palatal bone results in a
significantly off-axis implant position.
 If performed immediately, the long axis of the implant inclines
toward the buccal and will result in a significant esthetic
compromise of the definitive restoration.

 In these situations, the delayed approach should be used with

subsequent 3D bone and soft tissue augmentation of the
deficient ridge followed by optimal implant positioning.

88
 B. 2. BASED ON IMPLANT POSITIONING and
THE RESULTING LONG AXIS
[FUNATO et al 2007]

Funato el at. Timing, Positioning, and Sequential Staging in Esthetic Implant Therapy:
A Four-Dimensional Perspective. Int J Periodontics Restorative Dent 2007;27:313-23 89
 Vertical depth of implant head and direction of long axis
 The platform of the implant should be located 2 - 4 mm below
the mid-facial aspect of the free gingival margin, with the
extended long axis directed slightly lingual to the incisal edge
of the definitive restoration.

90
 When the long axis of the implant is inclined labially and
projects beyond the incisal edge of the definitive restoration,
the result is that the subgingival contours of the abutment or
restoration will tend to deflect the gingival margin apically,
resulting in an unharmonious esthetic profile.[Saadoun and Le
Gall 2003]

91
 To correct this problem, the profile extending from the implant
head to the free gingival margin requires a straight or negative
angulation.
 Immediate placement generally cannot be performed in the
wrong position without esthetic compromise.

92
 C. CLASSIFICATION OF EXTRACTION
SOCKETS BASED UPON SOFT AND HARD
TISSUE COMPONENTS
[JUODZBALYS et al 2008]

93
a. Soft tissue variables
1. Contour variations
 Vertical distance between the socket and adjacent teeth’s
buccal gingival scallop margin.

No gap < 2 mm > 2 mm

Adequate Compromised Deficient
94
a. Soft tissue variables
2. Vertical Soft tissue deficiency
 Vertical distance between the socket and adjacent teeth’s
buccal mucosa tissues margin.

No gap 1 - 2 mm > 2 mm
Adequate Compromised Deficient
Compromised Soft tissue
esthetic result augmentation prior to 95
implant insertion
a. Soft tissue variables
3. The keratinized gingival (KG) width on the mid-buccal
side of the socket.
• The existing KG helps tight tissue adaptation and provides a connective tissue
circumferential fiber system that resists mechanical stress. [Sevor 1992].

≥ 2 mm 1 - 2 mm < 1 mm
Adequate Compromised Deficient
Optimal for esthetic 96
restoration
a. Soft tissue variables
4. Gingival tissue Biotype

≥ 2 mm ≥ 1 - < 2 mm < 1 mm
Thick Moderate Thin

Claffey N, Shanley D. Relationship of gingival thickness and bleeding to loss of probing attachment97in
shallow sites following nonsurgical periodontal therapy. J Clin Periodontol 1986;13:654-657.
a. Soft tissue variables
5. Soft tissue quality

Pink and firm with Slightly red, soft Soft, edematous and
normal contour and spongy with boggy or crater-like
uneven contour appearance
Adequate Compromised Deficient

98
a. Hard tissue variables
1. Height of the alveolar process
Distance between the tip of the extraction socket labial plate and
the nasal sinus floor.

≥ 10 mm ≥ 8 - < 10 mm ≤ 8 mm
Adequate Compromised Deficient
99
a. Hard tissue variables
2. Available bone beyond the apex of extraction socket
 It is the distance between the socket apex and the nasal sinus floor.
 To achieve implant primary stability, available bone beyond the
extraction socket margin should be ≥ 4mm (or ≥ 3mm in case of
compromised bone height) [Nemscovsky 2002; Juodzbalys 2003].

100
a. Hard tissue variables
3. Extraction socket labial plate vertical position

• The distance between the tip of the extraction socket labial plate
and the CEJ of the adjacent teeth.

≤ 3 mm > 3 - < 7 mm ≥ 7 mm
Adequate Compromised Deficient
GBR IIP contraindicated. 101
a. Hard tissue variables
4. Extraction socket facial bone thickness
• Measured at the 1-, 2-, 3-, 4-, 5- and 6-mm levels with ridge
mapping calipers.

To maintain the implant soft tissue profile and to ensure implant esthetics, a
minimal labial plate width of 1 - 2 mm is needed. [Spray et al 2000; Kazor et al
2004]
102
a. Hard tissue variables
5. Presence of extraction socket bone lesions
 Periodontal and traumatic bone lesions often jeopardize the success of
immediate implant procedures.[Novaes et al 2003]
a. Hard tissue variables
6. Intradental bone peak height

3 - 4 mm ≥ 1 - < 3 mm < 1 mm
Adequate Compromised Deficient
103
a. Hard tissue variables
7. Mesio-Distal (M-D) distance between adjacent teeth

A minimum of 1.25 - 1.5 mm of clearance is needed between the implant

fixture and adjacent teeth for proper osseointegration and safety.

≥ 7 mm ≥ 5 - < 7 mm
Ideal Compromised
104
a. Hard tissue variables
8. Palatal angulation

< 5° 5° - 30°

Adequate Compromised

105
Treatment Recommendation Based on the Proposed Classification

Type I (Adequate) IIP

Immediate or Delayed
with simultaneous soft
Type II (Compromised)
or hard tissue
augmentation

Soft and hard tissue

augmentation or
Type III (Deficient) orthodontic treatment
followed by Staged
implantation.

106
 XI. TOOTH EXTRACTION AND IMPLANT
PLACEMENT PROCEDURES

Lazzara. Immediate implant placement into extraction sites: Surgical and restorative
advantages. Int J Periodontics Restorative Dent 1989;9[5]:333-43.
Becker and Goldstein. Immediate implant placement: treatment planning and surgical
steps for successful outcome. Periodontol 2000 2008; 47:79-89. 107
Atraumatic Tooth Removal Prior to Implant Insertion

 Teeth need to be
removed
atraumatically to
preserve the
maximum amount of
bone before
immediate implant
placement.
 The clinical situation
will dictate if the
tooth should be
removed flaplessly
(eg, if it is broken
subgingivally,
clinician’s
preference).
108
 In the esthetic zone, a buccal
flap should not be elevated
to reduce recession.
 Posterior teeth with multiple
roots should be sectioned
with burs prior to extraction
to avoid fracturing the
buccal bony plate or the
furcation bone.
 The bur is sunk into the PDL,
pressed against the tooth,
and circumscribed for 270°,
avoiding the buccal aspect.

109
 Burring severs the PDL, creates
space (preferably at the expense of
the tooth structure), and facilitates
tooth removal.
 Also, Surgical blades (#15, #15c),
Periotome (Posterior/Anterior) 
useful to luxate the root mesial–
distally and permit extraction.
 After extraction, the site is
thoroughly degranulated (Molt C2
curette ([HuFriedy, Chicago, IL]) &
if necessary, a large round bur.
 The socket should be carefully
examined to be certain that the
socket walls are intact.
110
 The apex of the socket should be penetrated for implant
placement in the usual manner, with attention paid to
preparing the recipient site for parallelism and significant
extension beyond the apex.

 This will ensure stability after proper alignment of the

implant.

111
 The surgical guide is
placed over the surgical
site and a sharp
precision drill is used to
penetrate the palatal
wall of the extraction
socket. This drill guides
the initial preparation
of an osteotomy.
 The axis of the implant
must correspond to
the incisal edges of the
adjacent teeth or be
slightly palatal to this
landmark.

112
 Depending on the size of the extracted
tooth and the implant to be placed, the
implant should usually exceed the
diameter of the root, providing
mechanical retention  primary
implant stability.
 It is advisable to place an implant a
minimum of 3 to 5 mm apically into
the bone to attain primary stability if
mechanical retention cannot be
achieved laterally.
 Occasionally, it is possible to place a
tapered implant into an extraction
socket with minimal to no osteotomy
preparation, thereby relying on the
threads’ engagement of the bone lateral
to the socket walls.
113
 The stability of the implant can be verified
using resonance frequency analysis (RFA).
 The torque registered on the drilling consul
can also be a good indicator of initial implant
stability. Torque resistance of 40 Newton
centimeters is indicative of initial implant
stability.

114
 Excessive torque should not be applied to the implant because
this may strip the implant threads or exert excessive
compression on the adjacent bone, potentially leading to bone
necrosis and implant loss.

 Fixture level impressions are frequently made immediately

after implant placement  facilitates the fabrication of
prosthetic abutments and provisional restorations.

115
 Abutments and
provisional restorations
can be inserted onto
implants once
osseointegration has
been verified after a
proper healing interval.
 A healing abutment can
be inserted on the top of
the implant. It should be
even with, or slightly
apical to, the adjacent
marginal tissues.
 Interproximal papillae
adjacent to the implant
can be adapted with
interrupted sutures
under minimal tension.
116
 The provisional
restoration is then
inserted, making certain
the pontic is clear of the
healing abutment.
 The provisional
restoration should have
an ovate pontic to
support the adjacent
tissues and help
preserve the soft tissue
anatomy adjacent to the
implant.

117
 The patient is
instructed in proper
postsurgical care and
sutures are removed
in 7–10 days.
 Restoration of the
implant can take
place once
osseointegration has
been confirmed
(maxillary anterior
region 4–6 months).

118
 In the event that an immediately placed implant
encroaches upon the maxillary sinus, it might be
prudent to postpone implant placement, augment
the sinus, allow for bone healing, and then place the
implant.

119
 XII. THE BONY GAP

-The Jumping Distance

- Horizontal Defect
- Horizontal Defect Dimension
- Peri-implant Space
- The Implant-to-socket Wall Space

Becker and Goldstein. Immediate implant placement: treatment planning and

surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89. 120
 On occasion, the marginal tissues do not adapt to the healing
abutment. With a wide gap, connective tissue will form between
the coronal implant aspect and the surrounding bone.
[Akimoto 1999]

 With small gaps, on the other hand, bone fill occurs between the
implant and the bone, with or without the use of grafting
material or barrier membranes.

[Botticelli et al 2003, 2004, 2005;]

121
 Botticelli et al 2004

 Produced 1.0–2.5 mm wide circumferential bony defects in

dogs. Over a 4-month healing period the circumferential defects
healed with bone fill-in. At a few sites, the labial bone adjacent
to the extraction socket was reduced in height. In implant sites
with reduced labial bone, proper bone healing occurred at
the mesial, distal, and lingual defect aspects.

Botticelli D, Berglundh T, Lindhe J. The influence of a biomaterial on the closure of a

marginal hard tissue defect adjacent to implants. An experimental study in the dog. 122
Clin Oral Implants Res 2004: 15: 285–292.
Botticelli et al 2004 (same authors)
 In another study, bony gaps were left between implants and
surrounding bone.

 Some test sites were augmented with bovine bone, alone or with a
resorbable barrier, while other sites were left to heal spontaneously.

 At 4 months, all the defects filled with newly formed bone and the
biomaterial placed in the marginal defect in conjunction with implant
installation became incorporated into the newly formed bone tissue.

 A high degree of contact was established between the bovine bone

particles and the newly formed bone.
Botticelli D, Berglundh T, Lindhe J. Resolution of bone defects of varying dimension
and configuration in the marginal portion of the peri-implant bone. An experimental
123
study in the dog. J Clin Periodontol 2004: 31: 309– 317.
 124

 In practice, when a bony

gap is present, no effort is
made to surgically advance
the flap.
 A small amount of allograft
or alloplast is layered
between the bony margin
and the implant abutment.
 This material is left
exposed. Within a few
weeks some of the material
will exfoliate and gingival
mucosa will migrate over
the exposed material 
providing an uneventful
healing.
 It is important to recognize that placement of bovine
bone, allografts, or other substances with or without
barrier membranes may support or improve soft
tissue contours; however, these materials cannot be
relied upon to enhance osseointegration.

125
126
127
128
Mechanism

 In the early period of healing, allograft particles were surrounded by

newly formed bone, confirming their capacity for osseoconduction,
but they did not form a real continuity with the socket bone. The
internal structure of the particles showed the presence of empty
osteocyte lacunae.

 They had a high degree of biocompatibility with the surrounding

tissue and were mainly replaced by newly formed bone at 3 months.

 The smaller number of residual particles due to higher resorbability

than xenografts or other biomaterials allows the regenerated bone
structure to be more similar to the original bone.
129
 A mineralized bone cortical allograft combined with a collagen
membrane allows a significant reduction in buccal and lingual
bone resorption, which was higher than observed using mineralized
bone cortical allograft alone.

 The membrane is used as a barrier to hold the mineralized bone

cortical allograft in place during the entire healing time. Therefore,
the real benefit of using a mineralized bone cortical allograft and
membranes in implant surgery is preserving bone volume and
enhancing osseointegration, which are the key factors for clinical
success.

130
 Implant-Bone Interface
 It is reasonable to
assume that spaces
exist between the
implant and the
prepared bone site
because of the shape
of the extraction
socket.
 The implant-bone
interface can be
classified as type I,
II, or lll.

Barzilay. Immediate implants: Their

current status. The International 131
Journal of Prosthodontics 1993;6[2].
 Type I

 This can be accomplished when the root is smaller than the

implant and is often seen when small teeth are extracted or
when the teeth that are extracted have had periodontal disease
and the remaining socket size is minimal.

 The type I interface can also be created when an alveolectomy

is performed, thereby allowing the implant to be placed into
basal rather than alveolar bone.

132
 Type II
 The space is present at the coronal aspect of the implant,
while the apical portion of the implant is secured in freshly
prepared bone.

Type III
 The Type III situation exists when a space is present along the
lateral border of the implant. This may be the reason that the
immediate implantation procedure was slow to develop, since
this gap may have initially concerned researchers as a possible
mode for failure.

133
XIII. SOFT TISSUE MANAGEMENT
[DECISION TREE]

134
 135

> 2mm < 2mm

 XIV. HISTOLOGICAL OUTCOMES
[HEALING FOLLOWING IIP]

Vignoletti and Sanz. Immediate implants at fresh extraction sockets: from myth to
reality. Periodontol 2000 2014;66:133-52. 136
 Berglundh et al 2003  histologically evaluated the early phases of
osseointegration after surgical insertion of endosseous titanium
implants into healed crests using the wound chamber model.

1. initially, the empty wound chamber become filled with a coagulum

and granulation tissue …

2. This granulation tissue was soon replaced by the provisional

connective tissue matrix.

3. During 1st week – Bone formation starts within the matrix, first
in contact with the parent bone by the appositional bone-formation
bed, although bone was also formed in direct contact with the
implant surface at a distance from the parent bone.
137
3. This primary (or immature) bone was formed by woven bone that
was soon remodeled into parallel - fibered and/or lamellar bone
and marrow that filled the entire chamber.

4. Percentage of BIC:

 4- day – 6.3%

 After week 1 – 24.8%

 At the end of 12 weeks – 65%.

138
 Vignoletti et al 2009  Studied the osseointegration after implant
installation in a fresh extraction socket.

 1. After 4 hrs -- the interior of the chamber was occupied with non-
mineralized tissue, mainly composed of erythrocytes and bone
remnants and debris resulting from drilling. Remnants of the
periodontal ligament attached to the bundle bone.

 2. After 1 week -- the wound chamber was mainly filled with

granulation tissue, which was rich in fibroblast-like cells within a
fibrin-like extracellular matrix. At this time, bone modeling was
absent, although abundant areas of bone remodeling were
observed in the parent bone.
139
 3. After 2 weeks -- Bone modeling was manifested, with woven bone
formation. New bone formation was observed, both in intimate
contact with the implant surface as well as adjacent to the parent
bone. A marked angiogenesis that paralleled the osteoblastic
activity was noticeable.

 4. At 4 and 8 weeks -- Both bone-modeling and bone-remodeling

events were observed.

 5. Percentage of BIC:

 Day 0 – 10-15%; Limited to the thread tip level of the implant.

 After week 1 – Decreased to 5%

 Upto 8 weeks – 45%. 140

 Comparison between both studies demonstrates that the
processes of de-novo bone formation and osseointegration are
similar, both quantitatively and qualitatively.

 However, in the immediate implant model, a more pronounced

osteoclastic remodeling phase was observed in the first 2
weeks, which translated to a decrease of approximately
10% of the BIC between 4 h and 1 week after implant
insertion.

141
Greenstein and Cavallaro. Immediate Dental
Implant Placement: Technique, Part 1. Dentistry
Today 2014.

142
143
XV. IIP IN INFECTED SITES

144
Introduction

 Some authors consider implant placement in chronic apical

lesions to be a contraindication.[Tolman 1991; Barzilay 1993]
 In fact, it has been postulated that periapical and periodontal
lesions have a negative effect on osseointegration, resulting in
implant failure. [Werbitt 1992].
 On the contrary, it has been demonstrated that immediate
implants placed into infected post-extraction sockets are a
predictable procedure with success rates close to 92%
[Lindeboom et al 2006].
 More recent literature, however, has investigated placement
into sites exhibiting periapical pathosis with successful
outcomes. [Naves, Del Fabbro, Crespi, Marconcini].

145
Indications
1. Periapical granuloma.
2. Periapical cysts.
3. Periradicular lesions.
4. Ligature-induced periodontal disease.
5. Endo-perio lesions.
6. Recurrent endodontic lesions.
7. Chronic periapical or periodontal pathology.
8. Fistula, suppuration or combination lesions.
9. Root – fracture, resorption, perforations.
10. Unfavorable crown-root ratio.
11. Subacute periodontal infection.

146
Contraindications

1. Recurrent infections.

2. Sites with uncontrolled infections.

3. Sites with inadequate supporting bone.

4. Systemic – uncontrolled diabetes, smoking..

147
XVI. LITERATURE REVIEW

148
 Waasdorp et al 2010
 Addressed the review on:

1. Does the presence of infection compromise the

osseointegration of immediately placed implants?

2. Does the presence of infection compromise immediate

implant placement success?

3. What protocols have been used to address the infection prior

to immediate implant placement?

The diagnosis of infection is often clinically based; clearly, periapical

lesions which present with a similar radiographic appearance can
differ histologically.
Waasdorp et al. Immediate Placement of Implants Into Infected Sites: A Systematic 149
Review of the Literature. J Periodontol 2010;81:801-808.
150
 Data from HUMAN studies  5 Case reports/Case series + 3
Comparative Clinical studies
Novaes & 3 patients, each with 1 IIP. [recurrent 100% success with a proof
Novaes 1995 [1st endo/periapical radiolucency] of principle – “patient must
case report] be placed on penicillin V
24-48 hours before the
procedure and maintained
on medication for 10 days.”
Villa and 20 patients – 97 implants [endo/perio] 100% survival.
Rangert 2005
Villa and 100 maxillary implants [76 in infected 97.4% survival rate.
Rangert 2007 sites vs. 24 in healed sites] –
endo/perio/root fracture.
Casap et al 2007 30 implants into infected sites in 20 97.7% survival rate.
patients [periodontal cysts, endo-perio, Complications – membrane
periapical, chronic periodontal exposure, minimal attached
infections] gingiva,
pseudomembranous colitis.
Naves 2009 3 IIP in 1 patient with 3 years follow- 100% survival.
up [chronic periapical]
151
 152

Lindeboom 50 patients (Test - 25 IIP in 92% vs. 100% survival in

2006 [1st infected sites vs. Control – 25 in Test vs. Control group.
prospective delayed installation 3months post- Microbes cultured
randomized extraction [chronic periapical from sockets.
study] pathology]. F. nucleatum and
P. micra were most
Follow-up – 1 year
prevalent.

Seigenthaler et 29 patients completed – 29 100% survival.

al 2007 implants (Test 13 vs. Control 16)
[periapical pathology, suppuration,
fistula, combination]
Follow-up – 1 year
Del Fabbro et 30 patients – 61 IIP in [Chronic 98.45% survival rate.
al 2009 periapical].
Follow-up – 10-21 months.
Del Fabbro 2009 
Evaluated the clinical outcome of implants immediately placed into
fresh extraction sockets of teeth affected by chronic periapical
pathologic findings, using plasma rich in growth factors (PRGFs) as an
adjunct during the surgical procedure.

 A total of 61 transmucosal implants were immediately installed in

30 partially edentulous patients after extraction of teeth with
chronic periapical lesions.

 All implants used had an acid-etched surface. Before placement, the

implants were embedded carefully in liquid PRGFs to bioactivate the
implant surface.
Del Fabbro M, Boggian C, Taschieri S. Immediate implant placement into fresh
extraction sites with chronic periapical pathologic features combined with plasma rich
in growth factors: Preliminary results of single-cohort study. J Oral Maxillofac Surg 153
2009;67: 2476-2484.
154
 The implant success and survival rate was 98.4% after 1 year of function
(100% in the maxilla and 96.8% in the mandible).

 According to the lesion type, 100% and 96.2% of implant success was
recorded in sites affected by endo-periodontal or endodontic lesions,
respectively.

 Why PRGFs? It is particularly indicated for immediate post-extraction

implants; combined with minute bone chips obtained during drilling
procedure, it could fill the gap between the implant surface and socket
walls, providing an osteoconductive, autologous graft that replaces and
improves the bone substitutes commonly used. The implant surface
adsorbed the protein-rich material, and osseointegration was enhanced when
the surface was covered with PRGFs.

155
 Data from Waasdorp’s review demonstrated 
High levels of implant survival in the presence of periodontal
and periapical infections.

Key points with respect to treatment protocol ---

1. Complete and thorough debridement of the socket..
2. Achieving primary stability..
3. Use of systemic antibiotics..

156
Fugazzotto in 2012

 Retrospectively assessed the implant survival rates when

immediate implants were placed in maxillary incisor region
with [mean follow up 64 months] and without periapical
pathology[mean follow up 62 months] in the same patient
(total 64 patients).

 Yielded cumulative survival rates of 98.1 and 98.2 for implants

placed in sites with periapical pathology and implants placed
in sites without periapical pathology, respectively.

Paul A. Fugazzotto. A Retrospective Analysis of Implants Immediately

Placed in Sites With and Without Periapical Pathology in Sixty-Four Patients.
157
J Periodontol 2012;83:182-186.
Minimal Requirements

158
Jofre et al 2012
 Reported 31 case series treated according to the protocol of asepsis
after extraction of infected teeth, and immediate implant placement
and provisionalization, and, presented a classification of implant
surface compromise in contact with previously infected tissue [CRAI].

Jofre et al. Protocol for Immediate Implant Replacement of Infected Teeth. Implant
159
Dent 2012;21:287–294
160
161
162
 Marconcini et al 2013

 Evaluated the 12 – month clinical success of 20 single-tooth implants

placed in infected fresh sockets.
 Prophylactic antibiotic treatment was prescribed for each patient (2 g
amoxicillin, 1 hour before surgery; thereafter, 1 g twice daily for 5
days).
 Twenty teeth were extracted as a result of an infection. Second stage
surgery was performed 4 months after the initial procedure.
 The healing period was uneventful for all the patients. All the
implants were osseointegrated. At the end of the 12-month follow-up
period, patients were asymptomatic and showed no signs of infection
or bleeding when probed.

Marconcini et al. Immediate Implant Placement in Infected Sites: A Case Series. 163
J Periodontol 2013;84:196-202.
 An infected tooth assumes the presence of bacteria in the socket.

 A direct consequence of the presence of bacteria in the socket is the

formation of granulation tissues that, at the same time, play a role in
the inflammatory response to bacteria as well as a barrier for the
bone.

 To conclude from the study, the control of the inflammation process

in the implant site by an early antibiotic prophylaxis may establish
a new homeostatic balance between bone resorption and new
bone formation, thus reducing risks of implant failure.

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XVII. RECOMMENDATIONS FOR CLINICAL
PRACTICE

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 When considering which implant protocol might be most
appropriate, the clinician must take into consideration different
factors: the patient; the location; and the surgical protocol.

 As for any other surgical implant protocol, the patient should be

free from oral infections and all previous oral conditions should
be treated before surgical implant placement.

 In patients affected by systemic diseases influencing wound

healing after implant surgery, such as diabetes, their systemic
status must be controlled before implant installation.

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 In terms of the location, the factors of major concern when
using the immediate implant protocol are:
 the thickness and the integrity of the socket bone walls,
mainly the buccal crest, as well as

 the gingival biotype.

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 From a surgical point of view, the implant design and implant
position may be the factors of major concern.

 Hence, when using the immediate placement protocol, the buccal

positioning of the implant and the use of implants that are too
congruent with the socket anatomy (tapered implants) should be
avoided.

 Implant placement must therefore be guided by the ideal prosthetic

position as well as by the assurance of primary stability in the apical
portion of the socket and the creation of an adequate gap dimension
(> 2 mm) between the implant surface and the inner buccal bone
plate in the coronal portion, to allow for adequate bone healing.
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THANK YOU 170