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Immediate Loaded Implants Placed

in Fresh Extraction Sockets - Effect

on Marginal Bone

Teemu Väkiparta

Tobias Neergaard- Richardt

Immediate Loaded Implants Placed in Fresh Extraction

Sockets - Effect on Marginal Bone

Teemu Väkiparta

Tobias Neergaard-Richardt

Tutor: Stefan Lundgren

ABSTRACT

This study investigated the immediate implant placement in the maxillary aesthetic zone

without flap elevation or enhancement of the hard tissue component with filler or

membrane material. The aim of this paper is to study treatment outcome for immediate

implant placement in fresh extraction socket in the maxillary anterior region regarding

marginal bone level.

This retrospective cross-sectional study includes data on 41 patients, total of 54

implants (n = 54), treated for immediate placed implants without flap elevation. 30

patients, a total of 33 single immediate implants were placed in the anterior maxilla and

immediately restored with a temporary crown. In another 11 patients, 21 implants were

placed in fresh extraction sockets and temporalized with a provisional bridge engaging

immediate implants and in some cases in combination with delayed implants.

No implants were lost during the follow-up period, mean radiographic follow up was 32

months. Analysis of the radiographs presented mean bone level of all sites 1.47 mm (SD

1.63) immediately after the installation and 0.85 mm (SD 0.75) at the follow up

evaluation, resulting in a mean bone gain of 0.62 mm.

With careful patient selection immediate placement of implant in fresh extraction socket

can be an attractive treatment modality in maxilla anterior region.

3

INTRODUCTION

A hopeless tooth scheduled for extraction is a common clinical problem facing dentists

all over the world, caused by caries, periodontal disease, endodontic complication, tooth

fracture, or trauma (Grandi et al., 2011). Screw shaped titanium implant has been an

attractive alternative to rehabilitate missing teeth in failing dentition (Brånemark et al.,

1977).

Traditionally clinicians have let the extraction alveolus heal for 2-3 months after the

extraction before inserting an implant into the jaw bone (Quirynen et al., 2007). The

implant has then been installed into the site after the healing period, using submerged

two-stage method where the implant is covered with soft tissue and left to

osseointegrate initially 6-8 months (Brånemark et al., 1977) later 6-12 weeks (Buser

and Chen, 2009). Alternatively, a one-stage method has been used where a healing

abutment is placed to the fixture at the primary implant surgery, and is kept out of

masticatory powers for at least 3 months (Buser et al., 1990). Elevation of a flap

contributes to bone resorption of the buccal wall because of the destruction of vascular

supply (Araújo and Lindhe, 2005). Flapless surgery or minimal flap elevation is

beneficial for preserving the crestal bone around the implant (Becker et al., 2005).

Osseointegration is defined as direct contact between living bone and implant. The

primary stability is achieved by mechanical retention of the threads of implant to the

tapped implant bed in jaw bone. Drilling procedure causes a wound around the implant

in jaw bone and the process of osseointegration initiates and results in bone healing. The

healing process follows the general wound healing stages of haemostasis, coagulation

formation in the space between implant and alveolus, and formation of granulation

tissue. During the first week, trabecular bone modelling starts and the bone tissue grows

from the alveolar bone to the implant by apposition (increase in bone volume on

existing bone). The secondary stability is gained by maturation of the newly formed

bone tissue. Primary stability decreases over time while the secondary stability

increases over time and after three to four weeks primary clinical stability is lost. Early

functional loading can be reached if the implant is placed in bone with optimal balance

4

between cortical and trabecular bone since the stability loss is less pronounced

(Bosshardt et al., 2017; Araújo et al., 2006).

The time span from extraction of the tooth to the final restoration with traditional

approach has been long and complicated for patients (Johannsen et al., 2012), and new

treatment modalities has been under development, aiming to reduce the overall

treatment time and number of surgical procedures (Quirynen et al., 2007). Trials has

been done on placing implant to fresh extraction socket, treatment modality called in

literature immediate implant. Temporary crown without any occlusal load can be

connected to the fixture after the placement giving the patient a direct replacement of

the extracted tooth (Laney, 2007). Survival rates for immediate implant placement into

fresh extraction socket has been promising, 92,3-100 % (Polizzi et al., 2000; Lorenzoni

et al., 2003; Consyn et al., 2011).

Upper jaw anterior region is a high aesthetic zone and can benefit from the ability to

immediate rehabilitation after the extraction. Diversity of studies of immediate

placement exist with different surgical approaches, both with or without flap elevation

and placement of filler material to residual gaps or usage of membrane. Some of the

authors have presented marginal bone gain around the implant between instalment and

follow-up (Barone et al., 2004; Cooper et al., 2010) and some bone loss (Grandi et al.,

2011; Kolerman et al., 2016; Soradi et al., 2012). Bone levels are of interest since the

level of marginal bone determines soft tissue level (Grunder, 2005). In this study, we

evaluate marginal bone healing of immediate implants without flap elevation or usage

of filler or membrane, in order to determine their impact to the healing and treatment

outcome.

The aim of this paper is to study treatment outcome for immediate implant placement in

fresh extraction socket in the maxillary esthetical region regarding marginal bone level.

5

MATERIALS AND METHODS

This study consists of two parts; marginal bone height analysis using intra oral

radiography and in addition a literature review on the topic of immediate placement of

implants in fresh extraction sockets and immediate restored with a temporary crown.

Appendix 1 illustrates a complete rehabilitation of a hopeless central incisor with the

concept of immediate implant placement.

Literature review

The authors designed keywords to find relevant litterateur for immediate installed

implants. The literature search was made in PubMed and were performed individually

for each author. The titles for each search were read, if the title of the article addressed

the purpose of the study, the abstract was read. If the abstract reported immediate

implants installation effect on the marginal bone level with radiographic measurements,

the article was read and analysed. The authors presented and discussed the relevant

articles found. 12 of the total 610 articles were used as a reference list. Reference lists

of the articles found during the literature search were carefully inspected and frequently

cited original articles relevant to the subject of immediate implant placement

complemented to our literature search (appendix 2).

Keywords: Immediate Dental Implant Loading, Maxilla, Dental Implants, Single-

Tooth, Immediate single-tooth implants, hard tissue response, Single Implant,

Comparison of bone level, extraction sockets, fresh extraction socket, bone-to-implant,

relationship, Immediate loading, single-tooth implant, maxilla, partial implant and

partial immediate implant.

Ethical consideration

Study material consisted of radiographs of patients which had already been treated in

Palermo, Italy. All patients were informed of the study and they have given their

consent to participate in this study. This study followed ethical principles of Department

of Odontology, Umeå University and was ethical approved by the ethical board of the

department. Authors of this paper didn’t have access to any medical records to ensure

the privacy of participants. The sample consisted of coded radiographs and information

6

of follow-up time and installed implant size. A few patients were decoded during the

quality control of the measurements, since the measurements of two measurers

differentiated significantly from each other. Therefore, the treatment quality of these

patients was controlled extra carefully.

Patient selection

This retrospective cross-sectional study includes data on 41 patients treated for

immediate placed implants. Thirty-three implants in 30 patients were placed in the

anterior maxilla by the concept of single immediate flapless placement in fresh

extraction sockets and immediate restored with a temporary crown for non-functional

loading. In another 11 patients, 21 implants were placed with the same concept of

immediate placement of the implants in extraction sockets. These implants were used in

implant-supported bridges. The same surgeon treated all the patients in a private

practise in Palermo, Italy.

The inclusion criteria were; Patients with one or several hopeless teeth, which needed

to be extracted in the anterior region of the maxilla. Teeth included were central or

lateral incisors, canines or bicuspids in patients at least 18 years of age and in a good

general health. Sufficient amount of bone apical or palatal to the alveolus of the

extracted tooth in order to ensure primary insertion torque of at least 25 Ncm for

splinted implants and 35 Ncm for single implant.

The exclusion criteria were; heavy smoking (more than 10 cigarettes a day), untreated

or uncontrolled periodontal disease, poor oral hygiene, acute infection at the failing

tooth site, soft and hard tissues defect that could impair the aesthetic outcomes of the

treated site.

Surgical protocol

All patients who were subjected to implant surgery had a clinical and intraoral

radiographic examination prior to the surgery. Evaluation was made if patient and the

site was suitable for treatment, and patient was excluded from the study if high

esthetical or functional risk of site was present. Risk factors were not limited but

included for example absence of sufficient keratinized mucosa, or a vertical and/or

7

horizontal soft tissue defect. These cases were treated with additional flap with or

without graft, or by letting the alveolus heal before implant placement.

Presence, absence or altered condition of post-extractive buccal or palatal bone has not

been considered as a parameter requiring additional bone graft or socket preservation

approach.

The surgeon together with patients, comparing the treating site to the contralateral tooth,

clinically performed this evaluation. The implant surgery was performed under

perioperative antibiotic treatment with Amoxicillin 1 g x 2 for 7 days, started 2 days

before surgery and maintained 5 days postoperative. Patients allergic to penicillin

received clarithromycin 250 mg x 2 for 7 days. Each patient received an individual oral

hygiene regimen before surgery and for the postoperative follow up at least once a year.

The surgery was performed under local anaesthesia. An intrasulcular incision was

performed around the tooth followed by an atraumatic extraction in order to maintain

the walls of the alveolar socket intact. The extraction socket was examined for

dehiscence and cleaned from granulation tissue. This was followed by a further

evaluation if the implant could be placed without an additional flap. The site was

prepared with maximal implant engagement with the apical and palatal residual bone to

achieve optimal implant primary stability. Nobel Active implants (Nobel Biocare) were

used, either with a diameter of 4,3 or 3,5 mm.

Implants were positioned to the dental arch using the neighbouring and opposite teeth as

reference. Final insertion torque was measured after placement. Distance between the

implant shoulder and neighbouring tooth was at least 1 mm in all cases. The implant

shoulder was positioned at least 3 mm below the former buccal gingival margin or its

most apical area in order to have enough peri-implant mucosa tunnel to compensate

diameter discrepancy between implant and crown.

Rehabilitation Protocol

A temporary crown is used to seal the alveolus from the oral cavity and allow the

support of the marginal soft tissue to maintain a good emerge profile. Prefabricated

8

acrylic temporary crown shell was intraorally relined and placed onto the temporary

titanium abutment and the temporary crown was screw retained. Provisional restorations

did not have any centric or eccentric occlusal contacts. The temporary crown was

fabricated with a straight and/or light convex sub-marginal profile especially in the

facial part, allowing to seal the gap between peri-implant mucosa margin and implant

but avoiding soft tissue compression. The permanent crown was delivered 3-6 months

after implant placement.

Radiographic follow-up

Digital periapical radiographs were taken using long-cone parallel technique.

Radiographs were taken before extraction (figure 1), immediately after implant

placements, before final restoration and after 15-61 month after functional loading

(figure immediate implants 1). The distance between the mesial and distal alveolar bone

crest to implant shoulder was measured (figure 1) using OsiriX Lite v.8.0 32-bit Pixmeo

SARL, Bernex. The distortion of the radiographs was calculated by dividing the

radiographic implant shoulder diameter by the actual one. Two independent groups

performed measurements of the radiographic images.

Statistical analysis

Data analysis was performed in IBM SPSS 22 and Excel. The mean, median and

standard deviation was calculated for measurements in respective sites. Standard

deviation is a value that shows the mean standard deviation in a population of normal

distribution. If the standard deviation is relatively large it implies a large difference

between the samples (Björk, 2011). Intra-class correlation (ICC) was calculated of the

two measurers in order to determine interrater reliability value. Interrater reliability test

is a comparison between measurements of two or more observers that shows the

agreement of the observers’ measurements (Björk, 2011).

9

RESULTS

Forty-one patients (26 women, 15 men) met the selection criteria and were treated with

the concept of immediate implant placement with Nobel Active implant system with 54

implants in total. The mean duration between implant installation and the evaluation

was 32 months (range 15-61 months). The measurements were done according to figure

1. No patients were excluded due to insufficient insertion torque, major flap elevation or

damage of the alveolar bone due to extraction. The mean insertion torque was 43 Ncm.

No implants were lost during the follow-up period. The implants were predominantly

installed below the marginal bone level, and the temporary crown sealed the extraction

alveolus from the oral cavity.

Analysis of the radiographs presented mean bone level of all sites 1,47 mm (SD 1,63)

immediately after the installation and 0,85 mm (SD 0,75) at the follow up evaluation.

Bone level gain was 0,62 mm. The average bone level before installation was for mesial

site 1,66 mm (SD 1,85) and for distal site 1,29 mm (SD 1,34). At the follow up

evaluation mean bone levels were 0,78 mm (SD 0,70) and 0,93 mm (0,80) for

respective sites, resulting in mean bone level gain for mesial site 0,88 mm and mean

bone level gain for distal site 0,36 mm. Mean bone gain for all sites was 0,62 mm

(figure 2).

Intra-class correlation (ICC) was calculated in order to compare the measurements made

by two independent groups. The ICC value for the mesial site was 0,92 and for distal

site 0,88 after immediate installation. The follow-up ICC value for mesial site was 0,85

and distal site 0,92 (Figure 3).

DISCUSSION

This retrospective study evaluates marginal bone level around implants placed into fresh

extraction sockets. The implant success rate in the present study was 100 %, which is in

correspondence with Lorenzoni et al., (2003) while Bell and Bell (2014) and Cosyn et

al., (2013) presented a lower success rate 92,9–93 %. A systematic review by Esposito,

Grusovin and Worthington (2013) stated that prophylactic antibiotic treatment may

reduce implant failure. The high success rate in the present study may be explained by

10

careful selection of patients. Comparison of different treatment modalities was difficult

to make since the present study didn’t include a control group.

The marginal bone level modification was carefully analysed between the installation

and follow-up. The gain in marginal bone level at mesial site was 0.88 mm between

installation and follow-up, and at the distal site 0.36 mm. Some of the implants were

installed on sites with no adjacent tooth distal to the implant, which might explain the

difference of bone healing between the mesial and distal site. The mean bone level was

1.47 mm at the follow-up, which is in line with Cooper et al., (2010). Kolerman et al.,

(2016) and Cosyn et al., (2013) had similar results, though with usage of filler material

in the residual gap between crestal bone and implant. Chu et al., (2015) placed implants

in fresh extraction sockets and studied the effect of bone graft with/or provisional crown

on facial-palatal ridge dimensional change. Their conclusion was that the group with

immediate placement and bone graft combined with either a contoured healing

abutment or custom-contoured provisional restoration yielded the smallest amount of

change in facial-palatal contour. Further investigation is needed in terms of comparison

of immediate placement of implant in fresh extraction socket with and without bone

grafting material in order to determine the role of the bone formation enhancement

material in the overall clinical outcome of this treatment modality. Different results in

marginal bone gain/loss between authors might depend on several different factors.

Implant design (diameter, macro and micro anatomy, prosthetic connection); implant

positioning (apico-coronal and bucco-lingual); distance from surrounding teeth;

prosthetic manufacturing represent just some samples of possible confounders.

However, the most critical variable, to our opinion is the management of the prosthetic

restoration, which can play a major role on marginal peri-implant bone and soft tissue

stability.

The implant installation is considered successful if the radiographic bone loss is less

than 1 mm in height and subsequently if annual marginal bone loss doesn't exceed

average of 0,1 mm (Albrektson & Zarb, 1993). In this study radiographs were taken at

implant installation and at a follow-up, which was between 15 and 61 months (mean 32

months). Different authors with similar studies have had different follow-up times

11

(Table 1) and therefore one has to be cautious when comparing these papers. Longer

follow-up period and great success indicates good long term predictability of a

treatment modality. A radiograph 12 months after the installation would had given a

picture of the early healing process with immediate implant. Some difficulties occurred

during the measurement of marginal bone levels from radiographs. Problems were

related mostly to non-optimal projection of the area. This leads to overlapping of the

adjacent tooth with the marginal bone of implant. In some cases both the buccal and

palatinal border of crestal bone was present in radiograph, and it was therefore difficult

to determine the marginal bone level. Eccentric projections made it difficult to calibrate

the radiographic analysis software, since the implant shoulder wasn't pictured in an

orthoradial way. Even though there were some difficulties with performing the

measurements due to problems stated above, all the ICC values for different sites were

over 0.8, which indicates a high accuracy of the measurements between two groups

(Altman, 1991, in Björk, 2012).

The literature presents various factors that may affect bone healing and resorption

around implants. Studies have attempted to find a correlation between the immediate

implant survival and smoking, but the sample size has been too small for statistical

verification (Bell and Bell, 2014). Greater bone loss and higher risk of implant failure

among smokers have been presented by some authors (Soardi et al., 2012; Wilson &

Nunn, 1999). Another factor presented in literature is plaque management.

Ramanauskaite and Tervonen (2016) presented in their systematic review the

importance of tailored peri-implant therapies and supportive oral hygiene treatment

regimens as part of the overall treatment. When any studies regarding immediate

implant instalment has excluded patients with poor oral hygiene, such as Kolerman et

al., (2016) and Cooper et al., (2010), one might argue that patient sample doesn’t reflect

the general population. Bell and Bell (2014) did not exclude patients with poor oral

hygiene which may explain the slightly weaker success rate.

Conclusions

Despite the limitations of this study, the results are promising that immediate placement

of implant in fresh extraction sockets can be a treatment modality to consider in the

12

anterior region of maxilla with careful selection of patients to be included. Longitudinal

studies of this treatment alternative in comparison with the traditional implant treatment

procedures is needed, as well as further research to determine if bone filler material in

residual gap of implant and crestal bone is beneficial and gives reduced marginal bone

loss. The outcome of the implant/soft tissue marginal aesthetic result needs to be further

evaluated.

ACKNOWLEDGEMENTS

We would like to pay our gratitude´s to Stefan Lundgren for the opportunity to write our

master thesis in the area of dental implants and for all guidance during the process. We

would like to thank Giovanni Cricchio who provided the patient sample and relevant

comments on our study, and Joakim Lundberg for measuring the sample and therefore

providing data for ICC calculations.

13

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Araújo MG, Sukekava F, Wennström JL, Lindhe J (2006). Tissue modeling following

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Berberi AN, Noujeim ZN, Kanj WH, Mearawi RJ, Salameh ZA (2014a). Immediate

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marginal bone level. J Contemp Dent Pract 15:202–208.

Berberi AN, Sabbagh JM, Aboushelib MN, Noujeim ZF, Salameh ZA (2014b). A 5-

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Björk J (2011). Praktisk statistik för medicin och hälsa. Stockholm: Liber.

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(2015). Flapless Postextraction Socket Implant Placement, Part 2: The Effects of Bone

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17

TABLES

Table 1 Immediate implants in maxilla

1Follow-up time unknown 2Mean follow-up for all study groups: 44 standard implant treatment (SIT), 28

immediate implant treatment (IIT),18 implant treatment in conjunction with guided

bone regeneration (GBR), implant treatment in grafted bone (BGR) harvested from the

chin. 3Succes rate for both maxilla and mandibular immediate implants, 48 in total.

Authors Number of

implants/patients

Follow-up time Success rate

Barone et al.,

(2006)

18 immediate

implants

1 year 94,5 %

Bell and Bell

(2014)

42 single unit

immediate implants

1 92,9 %

Berberi et al.,

(2014a)

20 immediate

implants

3 years 100 %

Berberi et al.,

(2014b)

22 immediate

implants

5 years 91 %

Cooper et al.,

(2010)

58 immediate

implants

1 year 94,5 %

Cosyn et al.,

(2011)

30 immediate

implants

3 years 96 %

Cosyn et al.,

(2013)

28 immediate

implants

3 years 93 %2

Grandi et al.,

(2011)

36 immediate

implants

1 year 97,2 %

Kolerman et al.,

(2016)

39 immediate

implants

Mean follow-up

44 months

94,7 %

Lorenzoni et al.,

(2003)

9 immediate implants 1 year 100 %

Polizzi et al.,

(2000)

130 immediate

implants

5 years 92,3 %

Soardi et al.,

(2012)

28 immediate

implants

1 year 95,7 % 3

18

FIGURES

Figure 1. A hopeless tooth scheduled for extraction (left radiograph). Implant inserted

into a fresh extraction socket after an atraumatic flapless extraction (middle radiograph).

Measurements were made from the first approximal crestal bone contact (marked with

red arrows in the radiograph) perpendicular to the tangent of the implant shoulder

(white arrow in the radiograph) for both mesial and distal aspects of the implant. Same

measurements were made for the follow-up radiograph (in the right). Notice how the

space between the extraction alveolar walls and implant is now filled by bone.

19

Figure 2. Mean radiographic distance between the reference point (implant shoulder)

and first radiographic approximal crestal bone contact for mesial and distal site both

after the instalment of the implant and at the follow-up. The measurements were

performed with a computer program after calibration of the program with the given

shoulder diameter. Both at the mesial and distal sites gain of crestal bone was seen

between the instalment and follow-up. The standard error is marked for respective

averages n=61.

20

Figure 3. Chart of intra-class correlation (ICC), presents the radiographic

measurements agreement between the observers for respective site and a mean value of

all measurements. Value of 1,0 means 100 % agreement between the measurers in all

measurements and 0,0 complete disagreement.

21

APPENDIX 1

22

APPENDIX 2

Pu

bM

ed s

earc

h

“Fla

ple

ss”

AN

D “

Tooth

extr

acti

on”

AN

D

“Im

pla

nts”

(n =

66)

“Im

med

iate

sin

gle

-too

th

impla

nts”

AN

D “

Har

d

tiss

ue

resp

onse”

(n =

10

)

“Sin

gle

im

pla

nt”

AN

D

“Tre

atm

ent”

AN

D

“An

teri

or

max

illa”

AN

D

“Rad

iog

rap

hic”

(n =

64

)

“Sin

gle

im

pla

nt”

AN

D

“Co

mp

aris

on o

f b

one

lev

el”

AN

D “

Ex

trac

tion

so

cket

s”

(n =

10

)

“Bon

e-to

-im

pla

nt”

AN

D

“Rel

atio

nsh

ip”

(n =

24)

“Im

med

iate

lo

adin

g”

AN

D

“Sin

gle

-to

oth

im

pla

nt”

AN

D “

Max

illa”

(n =

171

)

“Sin

gle

-too

th”

AN

D

“Par

tial

im

pla

nt”

AN

D

“Fre

sh e

xtr

acti

on

sock

et”

(n =

14)

“Par

tial

im

med

iate

im

pla

nt”

AN

D “

Fre

sh e

xtr

acti

on

sock

et”

(n =

29

)

“Im

med

iate

den

tal

impla

nt

load

ing”

AN

D “

Max

illa”

AN

D “

Den

tal

impla

nt,

sin

gle

-to

oth”

(n =

83

)

“Too

th s

ock

et/s

urg

ery”

AN

D “

Imm

edia

te d

enta

l

imp

lant

load

ing”

AN

D

“Den

tal

imp

lan

ts”

(n =

139)

Tit

les

scre

ened

(n =

61

0)

Tit

les

excl

uded

(n

ot

rele

van

t) a

nd

du

pli

cate

s re

mo

ved

(n =

53

5)

Fu

ll t

ext

read

, ar

ticl

es i

ncl

ud

ed i

n r

efer

ence

lis

t

(n =

12)

Art

icle

s ex

clu

ded

(n =

63

)

Po

ten

tial

ly r

elev

ant

arti

cles

, ab

stra

cts

scre

ened

(n =

75)

Umeå University

Department of Odontology

SE-901 87 Umeå, Sweden

www.umu.se