Daniele Botticelli Implants in fresh extraction sockets:

Antonio Renzi
Jan Lindhe
a prospective 5-year follow-up
Tord Berglundh clinical study

Authors’ affiliations: Key words: bone level, dental implant, immediate implant, radiographic evaluation,
Daniele Botticelli, Antonio Renzi, ARDEC Dental radiography
Clinic, Ariminum Odontologica, Rimini, Italy
Jan Lindhe, Tord Berglundh, Department of
Periodontology, Faculty of Odontology; Sahlgrenska Abstract
Academy at Göteborg University, Göteborg,
Sweden
Objective: The aim of this prospective study was to evaluate the 5-year clinical outcome of
the ‘immediate implants.’
Correspondence to: Material and methods: One week after the cementation of the prosthesis, a clinical
Daniele Botticelli
ARDEC Dental Clinic baseline examination was carried out. Clinical measurements were performed of the
Ariminum Odontologica following: plaque, mucositis, probing pocket depth, and soft tissue position. The height of
47900 Rimini
Italy the keratinized mucosa was measured at the buccal/lingual aspects. Standardized intra-oral
Tel.: þ 39 0541 393 444 radiographs were taken. The marginal level of bone to implant contact [radiographic (Rx)
Fax: þ 39 0541 397 044
bone level] was measured, and Rx bone level change over time was evaluated. The clinical/
e-mail: daniele.botticelli@ardec.it
radiographic measurements were repeated on a yearly basis. The subjects were enrolled in a
carefully supervised oral hygiene program.
Results and conclusion: It was demonstrated that ‘immediate implants’ that were loaded
after 5–7 months had a high success rate. During the 5-year interval, no implant was lost,
and the mean Rx bone level at the implants was maintained or even improved. The plaque
and mucositis scores were low (o20%) at baseline and at all re-examinations. Implant sites
located adjacent to the teeth showed bone gain during the initial period while sites that
were facing edentulous zones lost some bone.

The placement of implants in fresh extrac-
tion sockets was first described by Schulte
& Heimke (1976) and Schulte et al. (1978),
who referred to this procedure as ‘immedi-
ate implant.’ Several prospective (e.g.,
Yukna 1991; Becker et al. 1998, 1999;
Polizzi et al. 2000) and retrospective stu-
dies (e.g., Gelb 1993; Watzek et al. 1995;
Pecora et al. 1996; Goldstein et al. 2002)
reported high survival rates of such ‘im-
Date: mediate implants.’ Hämmerle et al. (2004),
Accepted 7 May 2008
in a consensus report, identified ‘immedi-
To cite this article: ate implants’ as belonging to the Type I
Botticelli D, Renzi A, Lindhe J, Berglundh T. Implants
in fresh extraction sockets: a prospective 5-year follow- procedure (‘implant placement immedi-
up clinical study. ately after tooth extraction and as part of
Clin. Oral Impl. Res. 19, 2008; 1226–1232
doi: 10.1111/j.1600-0501.2008.01620.x the same surgical procedure’) that, in
comparison with implant placement later
following tooth loss, may have advantages,
such as (i) reduced overall treatment time,
(ii) reduced number of surgical procedures
and (iii) an optimal availability of existing
bone to allow primary stability of the
titanium device. Furthermore, it was
claimed (e.g., Lindquist et al. 1988; von
Wowern et al. 1990; Denissen & Kalk
1991; Werbitt & Goldberg 1992; Dennisen
et al. 1993) that implant placement in a
fresh extraction socket may counteract the
hard tissue resorption and the resulting
reduction of the dimension of the edentu-
lous ridge. The validity of this claim, how-
ever, was not supported by data generated

1226 c 2008 The Authors. Journal compilation

c 2008 Blackwell Munksgaard

from recent experiments in dogs (Araújo et
al. 2005, 2006a, 2006b; Botticelli et al.
2006) and studies in humans (Covani et
al. 2003, 2004b; Botticelli et al. 2004).
Araújo et al. (2005) reported that after 3
months of healing following Type 1 im-
plant installation, the buccal bone had
undergone 2.6 mm of vertical resorption.
It was concluded that immediate implant
installation in a fresh extraction socket
‘failed to prevent the re-modeling that
occurred in the walls of the socket.’ Botti-
celli et al. (2004), in a clinical study,
installed 21 implants in fresh extraction
sockets in 18 patients. At surgical re-entry,
after 4 months of healing, it was observed
that most marginal gaps that were present
following implant placement were filled
with newly formed hard tissue, but also
that the buccal–lingual dimensions of the
ridge were markedly reduced (buccal
450%, lingual about 30%).
In a recent systematic review including
‘immediate implants’ (Quirynen et al.
2007), only two prospective (Prosper et al.
2003; Covani et al. 2004a) and four retro-
spective studies (Ashman et al. 1995;
Schwartz-Arad & Chaushu 1997; Huys
2001; Bianchi & Sanfilippo 2004) were
identified that included data with a fol-
low-up period of at least 4 years from
implant placement or loading. It was con-
cluded that although ‘immediate implants’
exhibiting a high survival rate, there was a
lack of long-term clinical and radiographic
data.
The aim of the present 5-year prospec-
tive study was to evaluate the long-term
outcome of implants placed in fresh extrac-
tion sockets, the short-term effects of
which were described by Botticelli et al.
(2004).
Material and methods
Eighteen consecutive subjects were re-
s
cruited at the ARDEC Dental Clinic,
Rimini, Italy. Before starting the trial, the
patients gave their informed consent. All
patients underwent a careful dental and
periodontal examination. This was fol-
lowed by oral hygiene instructions and,
when indicated, dental and periodontal
treatment. The patients were enrolled in a
supportive treatment including recall visits
once every 6 months.
c 2008 The Authors. Journal compilation


c 2008 Blackwell Munksgaard
Inclusion and exclusion criteria, as well
as treatment and examination procedures
were described previously (Botticelli et al.
2004). In brief, treatment was carried out
under local anesthesia. Full-thickness flaps
were elevated and the tooth was carefully
mobilized and removed. In this study, im-
plants of the Straumannt Implant System
(Institute Straumann, Basel, Switzerland)
were used. The socket was prepared for
implant installation in accordance with
the recommendations provided by the man-
ufacturer. A cylindrical implant (solid
screw, regular neck, SLA surface, diameter
4.1 mm; Straumannt) was installed. The
length of the implant used varied depending
on the depth of the socket; one implant was
8 mm, four were 10 mm and 16 were
12 mm long. The coronal margin of the
endosseous portion of the implant was
placed apical to the marginal level of the
buccal wall of the extraction socket. Mea-
surements were performed to determine the
size of the marginal defect present around
the implants. A closure screw (SCS closure
screwt; Institute Straumann) was placed
on top of the implants and the flaps were
sutured, allowing the closure screw to be
exposed to the oral environment. Sutures
were removed after 7–10 days.
A re-entry procedure was carried out
after 4 months of healing. Full-thickness
flaps were elevated and the measurements
were repeated. The closure screw was re-
moved and a healing abutment (SCS
healing capt; Institute Straumann, Wal-
denburg, Switzerland) was connected to
the implant. The flaps were re-adapted
around the healing cap and sutured.
Sutures were removed after 7–10 days.
The marginal defect around the implant,
the position of the bone crest in relation
to the implant shoulder and the width of
the buccal and lingual bone opposite to the
implant surface were determined at the
time of implant installation as well as at
re-entry; for details, see Botticelli et al.
(2004).
One to 3 months (mean, 1.4 months)
following re-entry, the prosthetic treat-
ment was completed. Ten cemented fixed
partial dentures and 11 single tooth restora-
tions were placed.
Out of 42 mesial and distal aspects
recorded at the experimental sites, 27
were present adjacent to the teeth, nine to
implants and six to edentulous areas. Most
1227 |
Botticelli et al . Implants in fresh extraction sockets
of the experimental sites (90%) had at least
one aspect (mesial or distal) facing a tooth
surface.
The position of the experimental sites,
the reason for extraction, the implant
length, the character of the adjacent ap-
proximal region (tooth, implant and eden-
tulous), the abutment used and the type
of prosthetic reconstruction delivered are
presented in Table 1.
One week after the cementation of the
prosthesis, a clinical baseline examination
was performed. The following parameters
were recorded for four aspects (mesial,
buccal, distal and lingual) of each implant
site: plaque (presence or absence), mucosi-
tis (bleeding after probing to a depth of
about 2 mm below the soft tissue margin),
probing pocket depth (PPD) and soft tissue
position (with respect to the restorative
crown margin). The height of the kerati-
nized mucosa was measured at the buccal
aspects (in both the upper and the lower
jaws) and the lingual aspects (in the lower
jaw). The linear measurements were ap-
proximated to the nearest millimeter.
The clinical measurements were re-
peated after 3 and 6 months and subse-
quently on a yearly basis during the 5-year
observation period.
Standardized intraoral radiographs were
taken, using individually fabricated film
holders, at the baseline examination, after
6 months and at annual follow-up exam-
inations. The marginal level of bone to
implant contact [radiographic (Rx) bone
level] was measured from a reference point
on the implant (shoulder) to the marginal
bone-to-implant contact level with the use
of a magnifying lens (Scale Lupe Peak
 10, West Chester, PA, USA). Rx bone
level and Rx bone-level change over time
were evaluated (Tables 2 and 3). In the
radiographs, the bone level (at baseline) at
the neighboring tooth surfaces as well as
longitudinal bone-level change at such sur-
faces were also determined.
Data analysis
All available data from all examinations
were included in the analyses. The primary
outcome variables were implant loss and
peri-implant bone-level change. Statistical
evaluations (Student’s t-test, considering
P-values o0.05 as statistically significant)
Clin. Oral Impl. Res. 19, 2008 / 1226–1232
Botticelli et al . Implants in fresh extraction sockets

Table 1. Patients abbreviation, implant position, reason for extraction, implant length, status of the adjacent areas, abutment type and
type of prosthesis
Patient Implant position Reason for extraction Implant length Adjacent area Abutment type Type of prosthesis
m d
M. B. 34 Caries 10 t e Solid FPD
M. T. 44 Caries 10 t e Solid FPD
I. O. 14 Caries 8 t t Solid Single
T. M. 14 Root fracture 12 t i Octa Single
R. M. 24 Caries 12 t t Solid Single
A. V. 24 Root fracture 12 t i Solid Single
M. F. 14 Caries 12 t i Solid Single
P. F. 23 Caries 12 t i synOcta FPD
M. C. G. 15 Root fracture 10 t t Solid Single
B. M. 15 Caries 12 t t Solid Single
R. R. 24 Caries 10 t i Solid FPD
I. B. 44 Caries 12 t t Solid Single
L. B. 14 Caries 12 t t Solid Single
L. C. 15 Caries 12 t t Solid Single
L. D. P. 1 13 Caries 12 i t Solid FPD
L. D. P. 2 24 Caries 12 i t Solid FPD
G. C. 15 Caries 12 t t Solid Single
F. A.1 43 Caries 12 e i Solid FPD
F. A.2 44 Endodontic 12 i e Angled FPD
E. M. C. 1 21 Endodontic 12 e t synOcta FPD
E. M. C. 2 12 Endodontic 12 e t synOcta FPD

t, tooth; i, implant; e, edentulous; FPD, fixed partial denture; m, mesial; d, distae.

Table 2. Clinical conditions and radiographic (Rx) measurements at the various visits, from the baseline examination (delivery of
prosthesis) to the 5-year follow-up
Visit Plaque Mucositis Probing depth (mm) Peri-implant mucosa level in Keratinized Distance
(%) (%) relation to the restorative crown mucosa (mm) S–B on
margin (mm) Rx (mm)
Buccal Lingual Proximal Buccal Lingual Proximal Buccal Lingual Proximal
Baseline 15 17 2.3 (0.9) 2.9(0.6) 2.9 (0.7) 0.8 (1.1) 1.5 (1.1) 1.7 (0.9) 3.5 (1.3) 2.4 (1.8) 2.74 (0.57)
3m 13 15 2.1 (0.7) 2.8(0.7) 3 (0.8) 0.6 (1) 1.5 (1.1) 1.8 (0.9) 3.5 (1.2) 2.4 (1.8)
6m 11 19 2 (0.7) 2.8(0.6) 2.9 (0.7) 0.5 (1.1) 1.5 (1) 1.7 (0.6) 3.6 (1.3) 2.3 (1.3) 2.74 (0.52)
1y 14 18 2 (1) 2.5(0.7) 2.7 (0.7) 0.4 (1.2) 1.3 (1) 1.8 (0.6) 3.5 (1.2) 2.5 (1.3) 2.64 (0.52)
2y 13 18 1.7 (0.9) 2.5(0.8) 2.6 (0.7) 0.4 (1.2) 1.1 (0.9) 1.8 (0.6) 3.5 (1.2) 2.7 (1.1) 2.6 (0.54)
3y 17 17 2 (0.9) 2.5(0.8) 2.9 (0.7) 0.3 (1.2) 1 (1.1) 1.9 (0.6) 3.3 (1.4) 2.1 (1.4) 2.56 (0.53)
4y 15 20 1.9 (0.8) 2.7(0.9) 3 (0.9) 0.3 (1.2) 1 (1.2) 1.9 (0.6) 3.3 (1.5) 2 (1.4) 2.54 (0.57)
5y 13 15 2.1 (1.1) 2.8(1.2) 2.9 (0.9) 0.4 (1.3) 1 (1.1) 2 (0.6) 3.2 (1.5) 2 (1.4) 2.51 (0.55)

S, shoulder of the implant; B, marginal bone-to-implant contact; m, month; y, year.

Mean values and SD are reported.

regarding Rx bone-level change were per-
formed from bone-level measurements
representing baseline and the various re-
examinations. Data from the clinical eva-
luations were considered as descriptors;
mean values and SD were calculated.
Results
No implant was lost during the 5 years of
follow-up. Five buccal sites exhibited soft
tissue recession to expose the margin of the
metal restoration; four were located in the
lower jaw. Figure 1 illustrates one case from
the current sample. A fractured upper first
premolar (Fig. 1a) was extracted and an
implant was placed in the fresh extraction
socket (Fig. 1b). An additional two im-
plants were placed in the fully healed ridge
distal to the ‘immediate implant.’ After
about 6 months of healing, the case was
restored with three separate porcelain
crowns (Figs 2a and b) and maintained in
a meticulous maintenance program for the
entire 5 years of observation. Figures 2c and
d illustrate the clinical and radiographic
status of the case at the 5-year examination.
Clinical findings
During the follow-up period, the mean
percentage of experimental sites harboring
plaque varied between 11% and 17%,
while the percentage of sites with mucosi-
tis varied between 15% and 20% (Table 2).
Throughout the study, the lingual aspect
presented higher prevalence of both plaque
and mucositis than the buccal and proxi-
mal sites.
At the 5-year examination interval, the
mean PPD varied between 2.1 mm (buccal)
and 2.9 mm (proximal) aspects (Table 2).
Out of 84 aspects evaluated, 67 had a
PPD  3 mm, 15 aspects presented a PPD
of 4–5 mm, while the PPD of the remain-
ing two aspects was  6 mm.
The marginal level of the peri-implant
mucosa at the 5-year visit located was
above the margin of the restoration:

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c 2008 Blackwell Munksgaard
 Botticelli et al . Implants in fresh extraction sockets

Table 3. Mean bone level gain (mm), SD and P-value from the baseline (delivery of the lingual aspects, respectively. Both the
prosthesis delivering) and the different follow-up examination, at implant and patient buccal and the lingual recessions were
level
Baseline to Implant level Patient level
more marked in the lower than in the
upper jaw: buccal aspect  0.2  1 mm
6m 0 (0.35) NS 0.05 (0.33) NS
1y 0.1 (0.39) NS 0.16 (0.37) NS
(upper) and  1.2  1.8 mm (lower); lin-
2y 0.14 (0.41) NS 0.2 (0.38) Po0.05 gual aspect  0.4  1 mm (upper) and
3y 0.19 (0.4) Po0.05 0.25 (0.38) Po0.05  0.9  1.3 mm (lower). The mean width
4y 0.2 (0.43) Po0.05 0.27 (0.41) Po0.05 of the keratinized mucosa decreased during
5y 0.23 (0.43) Po0.05 0.3 (0.41) Po0.05
the 5-year interval: about 0.3 mm at the
m, month; y, year. buccal (upper and lower jaw) and 0.4 mm at
the lingual aspect (lower jaw).

Radiographic findings

Table 2 presents the outcome of the Rx

bone-level measurements. At baseline,
the most coronal bone to implant contact
was located at 2.7  0.57 mm from the
implant shoulder while the correspon-
ding distance after 5 years was 2.5 
0.55 mm, i.e. gain of 0.2 mm. The long-
itudinal Rx bone-level improvement was
statistically significant both at the implant
and at the patient level. Table 3 illustrates
the distribution of implants with respect to
Fig. 1. Radiographs illustrating a first upper premolar at the time of the diagnosis of a root fracture (a) and with
their Rx bone level at baseline and at the
an ‘immediate implant’ installed (b).
various re-examination. Bone loss was de-
tected at six implants, while all the remain-
ing implants showed various degrees of
bone gain (Fig. 3).
During the 5-year period, implant as-
pects (mesial/distal) that were facing tooth
surfaces showed a higher degree of Rx
bone gain (0.39  0.59 mm) than implant
sites that faced adjacent implants (0.04 
0.59 mm). The Rx bone loss was detected
at aspects of implants that were facing
edentulous sites (  0.17  0.44 mm).
At the majority of the implant sites, RX
bone-level change occurred during the first
year of maintenance following the baseline
examination (Table 4).
In the 5-year period, the mean Rx bone
loss at the tooth surfaces adjacent to im-
plants was  0.20  0.24 mm (site level)
and  0.18  0.21 mm (patient level).

Fig. 2. Two implants were placed in the fully healed ridge distal to the immediate implant. The implants were
restored with three single porcelain crowns (a) supported by the three implants (b). The outcome of treatment
Discussion
after 5 years is illustrated in (c, d). Note that the volume of the soft tissue remained stable in the interval between
6-month and 5-year follow-up and that the bone level in the corresponding interval remained unchanged. The present prospective clinical study de-
monstrated that implants (i) installed in
0.4  1.3 mm at the buccal, 1  1.1 mm of the mucosa moved in the coronal direc- fresh extraction sockets and (ii) loaded after
at the lingual and 2  0.6 mm at the tion at the proximal aspects (about 5–7 months had a high success rate. Thus,
proximal surfaces (Table 2). During the 0.3 mm), while there was an overall reces- during the 5 years of observation, no im-
5-year period of observation, the position sion of 0.4 and 0.5 mm at the buccal and plant was removed, and the mean Rx bone

c 2008 The Authors. Journal compilation

c 2008 Blackwell Munksgaard 1229 | Clin. Oral Impl. Res. 19, 2008 / 1226–1232
Botticelli et al . Implants in fresh extraction sockets

been lost; four were early failures. In this

context, however, findings by Perry &
Lenchewski (2004) must also be consid-
ered. They reported that about 10% of
‘immediate implants’ were lost during a
6–67-month (mean: 34 months) period and
that most failures occurred during an early
phase of healing.
In the present study, it was observed that
the overall mean bone level improved, and
the overall bone gain amounted to
0.23  0.43 mm (implant level). A more
detailed examination of the present sample
(Fig. 1) revealed that six implants (29%)
in fact exhibited some loss of marginal
bone (  0.22  0.22 mm), while the re-
maining 15 implants (71%) gained bone
(0.41  0.35 mm).
In the current sample, it was observed
that most bone-level change occurred dur-
ing the course of the first 12 months
following baseline. Thus, at five implants
there was, during this initial period, a mean
Rx bone loss that amounted to  0.14 
0.05 mm, while 13 implants gained
0.21  0.14 mm bone. In the interval be-
tween 1 and 5 years, only a few implants
exhibited additional, albeit minor bone-
level change. This is in agreement with
the findings presented from prospective
studies by Wennström et al. (2004, 2005),
who placed implants in the healed ridge.
They reported that most bone-level change
Fig. 3. Diagram describing the distribution of implants according to bone-level change between baseline and 5
occurred during the first years after loading,
years. Six implants (red dots) lost some marginal bone while the remaining implants (blue) gained bone. Only
one implant lost 40.5 mm bone during the 5-year observation period. and that subsequently only a minor
changes took place. Moreover, Wennström
et al. (2005) found that 50% of the im-
Table 4. Number of implants (N) presenting bone loss or gain and corresponding mean plants exhibited no Rx bone loss after 5
bone level change and SD between visits years and that 28% of implants presented
Intervals Bone loss Bone gain
an improved bone height (40.5 mm).
N implants mm SD N implants mm SD The baseline examination of the present
BL–6 m 11  0.24 (0.22) 9 0.31 (0.24) study was performed about 6 months after
6 m–1 y 5  0.14 (0.05) 13 0.21 (0.14) tooth extraction. The finding that most
1–2 y 7  0.09 (0.04) 9 0.16 (0.1)
bone-level change occurred during the first
2–3 y 3  0.07 (0.03) 13 0.09 (0.03)
3–4 y 7  0.1 (0.04) 9 0.11 (0.03) year after implant installation is therefore
4–5 y 4  0.05 (0) 10 0.09 (0.04) in close agreement with data documenting
BL–5 y 6  0.22 (0.22) 15 0.41 (0.35) that the alveolar crest is undergoing a
BL, baseline; m, months; y, years (implant level). marked change after tooth extraction (e.g.,
Pietrokovski & Massler 1967; Johnson
1969; Schropp et al. 2003). Thus, the
width of the buccal and lingual bone walls
level at the implants was maintained or (for a review see Quirynen et al. 2007). will be diminished (Pietrokovski & Mass-
even improved. Thus, in studies by, e.g., Prosper et al. ler 1967) and, in particular, the height of
The favorable outcome of ‘immediate (2003) and Covani et al. (2004a), more the buccal socket wall will be reduced
implants’ observed in the present study than 270 implants were placed in fresh (Schropp et al. 2003; Araújo et al. 2005).
confirms data reported previously from extraction sockets, and after an observation In their prospective study, Schropp et al.
prospective as well as retrospective studies time of 4 years, only eight implants had (2003) showed that most of the reduction

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c 2008 Blackwell Munksgaard

of the ridge occurred during the first
3 months after tooth extraction but also
that an additional, although less pro-
nounced, change occurred in the interval
between 3 and 12 months. It was further-
more reported (Araújo et al. 2005, 2006a)
that implant placement in the fresh extrac-
tion socket failed to counteract buccal ridge
alterations that followed tooth loss.
In the present study, it was observed that
implant sites (mesial and distal) that were
located adjacent to teeth gained some bone
(Rx bone gain ¼ 0.39) during the initial
period (6–12 months), while sites that
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1232 | Clin. Oral Impl. Res. 19, 2008 / 1226–1232 c 2008 The Authors. Journal compilation


c 2008 Blackwell Munksgaard