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 Table of Contents  
Year : 2014  |  Volume : 1  |  Issue : 1  |  Page : 14-18

Immediate implant in the esthetic zone: An evidence-based clinical guide

Vice Dean for Post Graduate Studies and Research, Riyadh Colleges of Dentistry and Pharmacy; Chairman of Saudi Board in Prosthodontics, Riyadh, Saudi Arabia

Date of Web Publication2-Jan-2014

Correspondence Address:
Mansour K Assery
P. O. Box 84891, Riyadh 11681
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/WKMP-0056.124180

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Immediate implant placement in the esthetic zone is a topic that has recently received a lot of attention in the literature. Successful implant placement at the time of extraction in the esthetic zone is a challenge, requiring management of soft-tissue, atraumatic extraction placement of the implant and later the prosthetic stage.
This article looks reviews recent literature on the topic of immediate implant placement in the esthetic zone and the clinical steps involved. The article also looks at recent evidence on patient satisfaction and discusses the merits, demerits of such a procedure and precautions to be taken by the practitioner to minimize failure.

Keywords: Anterior teeth, esthetic zone, immediate implant, implant prosthesis

How to cite this article:
Assery MK. Immediate implant in the esthetic zone: An evidence-based clinical guide. Saudi J Oral Sci 2014;1:14-8

How to cite this URL:
Assery MK. Immediate implant in the esthetic zone: An evidence-based clinical guide. Saudi J Oral Sci [serial online] 2014 [cited 2023 Mar 21];1:14-8. Available from: https://www.saudijos.org/text.asp?2014/1/1/14/124180

  Introduction Top

Over the past decade, there has been a growing volume of literature on the placement of implants in the Esthetic Zone. [1] The growing consensus among prosthodontists and surgeons is that a successful implant requires not only osseointegration, but also consideration of the gingival esthetics and the esthetics of the final restoration. [2],[3],[4],[5] One of the greatest challenges facing an Implant Practitioner today is dependably and esthetically replacing a maxillary anterior tooth. [6],[7] Traditional techniques have called for tooth removal, alveolar healing, implant placement and integration, uncovering and possible soft-tissue grafting before finally completing the restoration. [8] This can result in multiple surgeries, many months of waiting and a long time wearing an inconvenient interim removable partial denture.

Attempts to shorten the overall length of treatment have focused on the two approaches:

  1. Early or immediate loading following implant placement. [9],[10],[11],[12],[13],[14]
  2. Immediate implant placement in the fresh extraction of the natural tooth. [8],[15],[16],[17],[18]

Recently although there has been growing evidence to suggest that immediate implant placement, followed by early implant loading can result in good results for the patient. [19],[20],[21] However, concerns have been raised about the clinical dilemmas associated with the technique. [22],[23] Given this the aim of this review of literature is to describe the technique for a single visit implant placement in the esthetic zone and review the literature to provide the practitioner with evidence based guidelines to minimize complications.

  Criteria for Immediate Implant Placement Top

One of the factors, highlighted by several authors, to improve the outcome of immediate implants placed in the esthetic zone has been case selection. [1],[17],[18],[23],[24] Immediate implant placement is most commonly indicated when tooth extraction is due to trauma, endodontic failure, root fracture, internal or external resorption, or extensive decay and the bony walls of the alveolus are still intact. [19]

It is contraindicated:

  • In the presence of active infection;
  • When there is insufficient bone beyond the tooth socket apex for initial implant stability;
  • When there is a wide and/or long gingival recession.

Prior to extraction, a tooth should be esthetically evaluated to comprehensively assess the potential implant recipient site. It has been reported that despite atraumatic extraction defects could exist in the alveolar septum that could jeopardize the success of the implant. [17] A proper plan should include a soft-tissue treatment protocol and a set of well-defined esthetic goals. [1],[19]

The tooth to be extracted must be evaluated based on its relative position to the remaining dentition in three planes of space, because the existing tooth position will influence the configuration of the gingival architecture. [17],[25],[26] An optimal extraction situation provides the potential for immediate implant placement if the diameter of the head of the implant closely matches the mesiodistal width of the coronal aspect of the socket. [1],[4]

  Extraction Technique Top

An atraumatic extraction is the key to successful placement of a single visit implants in the esthetic zone. Recent studies have shown that it is important to ensure that there is both adequate buccal bone thickness [26],[27] as well as an intact inter-alveolar septum [16],[17] to ensure good prognosis of the placed implant.

A number of instruments have been developed for this purpose, including the periotome. The periotome, a slim elevator - like instrument, is introduced into the periodontal ligament space and use to serve the periodontal ligament. This instrument is gradually advanced toward the apex of the tooth. Care should be taken to preserve the thin buccal wall of the maxillary incisors. Sectioning of the tooth and minimally invasive extraction have been proposed as a method to preserve the integrity of the socket whereby the tooth is carefully sectioned and the fragments carefully removed. [16] Recently, a technique of orthodontically extruding the hopeless tooth has been suggested as a means to increase the thickness of the labial bone. [28]

The osseous - gingival tissue relationship must be verified following tooth extraction. The desired level of the free gingival margin must be determined before implant restoration and must be related to the underlying osseous support. [1]

  Implant Placement Top

Several clinical reports have proposed implant placement without flap elevation (flapless surgery) to minimize bone loss and soft tissue recession. [1],[21] Chu et al. [21] so far as to recommend flap-less extraction and implant placement as a guideline to ensure clinical success of the implant.

Achievement of initial stability of the implant and sufficient quantity and quality of bone present are the key factors for success. [17],[18],[27],[29],[30] Given the fact that atraumatic extraction alone does not guarantee the absence of minor bone defects, especially in the intra-alveolar septum, [17] a host of bone and soft tissue augmentation techniques have been suggested to prevent failure of the implant and ensure good esthetics. [5],[28],[31],[32]

The primary stability of the implant should be the result of mechanical fixation of its implant and can be achieved by engaging the palatal wall and bone more than 2-3 mm beyond the apex of the extraction socket. This can be accomplished by positioning the burs against the palatal wall of the socket during the sequential osteotomy. [1]

Following atraumatic tooth extraction, initial preparation of the osteotomy begins with a 2 mm round drill with copious irrigation, through the surgical guide for optimal mesiodistal positioning. To avoid damage to the buccal cortical plate, the drill tip should be positioned along the palatal wall of the extraction socket, 3-5 mm coronal to the apical end of the extraction socket. [33],[34]

The implant is placed into sound bone along the palatal wall of the extraction site, away from the buccal wall of the socket and the socket itself. Maintaining a small gap between the implant and the labial plate may facilitate secondary bone fill with autogenous bone obtained with the bone collector device and establish thicker, more stable bone thus increasing resistance to bone resorption. [30] The need for bone grafting depends on the thickness of the labial plate rather than the size of the gap since the labial plate has a tendency to resorb in all directions. [18],[29] The final implant diameter should be within the confines of the tooth socket, without engaging the corona portion of the labial plate to prevent perforation and more important, bone resorption and soft-tissue recession. [4],[29]

After an immediate implant placement into extraction socket, it is critical to assess the horizontal space, if any, from the implant surface to the socket wall. It has been shown that no bone augmentation is needed if the peri-implant space is 2 mm or less because spontaneous bone fill and osseointegration will take place when using a rough surface implant. [33] In sites where the peri-implant horizontal defect measures more than 2 mm, a bone regenerating technique is required to predictably achieve bone fill and increase the percentage of bone-to-implant contact.

  Preservation of the Restorative Gingival Interface Top

Preservation of the gingival papilla and good gingival contour is critical for the esthetic success of implants in the esthetic zone. In this regard, the role of the provisional prosthesis used during the healing period is an important one. [35] The design of the provisional should minimize post-surgical irritation and pressure on the soft-tissue. Immediate installation of a provisional restoration, soft-tissue adaptation to the provisional and no-suture surgery favor soft-tissue healing. [33],[36] The role of the periodontist and the restorative dentist in this regard is an important one and it is critical that a good multi-disciplinary treatment plan is established before the procedure is attempted. [37] The use of scalloped implants and proximal shields for the preservation of the papillary esthetics has been suggested. [38],[39] It has also been shown that long-term stability of papillary esthetics is significantly better in individuals with a thick gingival biotype when compared with those with a thin gingival biotype. [40],[41]

  Occlusal Considerations Top

During immediate placement of a dental implant in the esthetic zone, utmost care must be given to occlusal considerations. Mild variations may exist depending on whether early or late loading of these implants and the presence of underlying conditions such as periodontitis. [9],[14],[42]

It is generally stated that in the maximum intercuspation and/or exclusive movements of the mandible, contact with the restoration should be avoided. In this way, any forces directed toward the tooth will inevitably be reduced by the interspersed bolus of force. Short of some parafunctional habit involving a hard object, the forces on the underlying healing implant should be relatively few, infrequent and low in magnitude.

  Implant Loading Protocols Top

Conventionally it has been argued that since, most gingival recession (0.7-0.9 mm) occurs within the first 3-6 months post implant placement and 80% of all sites exhibit buccal recession, a minimum of 3 months should elapse for the gingival tissue to stabilize before either selecting a final abutment or taking the final impression [Figure 1], [Figure 2], [Figure 3]. [1]
Figure 1: An ideal atraumatic extraction should aim to preserve both interdental papilla and the bone

Click here to view
Figure 2: A conceptual graphic description for implant placement in the anterior esthetic zone

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Figure 3: A provisional restoration is placed until healing of the tissue (a) followed by placement of the permanent restoration (b)

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There have been attempts made to load immediate implants with a final restoration soon after implant placement. However, a recent review of the literature showed that the 1 year survival for such implants was only 10%. [9] The same study however also pointed out that there is a paucity of prospective cohort studies addressing patient-centered outcomes and no parameters specific to immediate loading protocols were available for evaluation. [9]

  Advantages of the Technique Top

The concept of immediate implant placement on the fresh extraction socket has great attention over the last few years. [15] Reports on early and immediate loading have generally been very encouraging [24],[25] , while immediate post-extraction implant placement has allowed prosthetic treatment as early as 3-6 months post-surgery, with excellent esthetic results, along with good bone preservation, reduced treatment time and cost. [24],[25],[26],[27]

Furthermore, this widely used treatment modality has a psychological benefit for patients, as the loss of a tooth can often be a traumatic experience. However, with immediate implants, such "loss" can be limited and timely compensated through simple surgical and restorative procedures that can be completed in just a few months. [3]

  Conclusion Top

Over the past few years, there have been that studies have shown that immediate implants are comparable, if not superior to delayed placement in terms of survival, bone stability, papillary esthetics and patient satisfaction. [14],[20],[42],[43] In the view of the literature reviewed here it can be predicted that immediate implant placement is a safe and reliable technique to provide implants in the anterior esthetic zone.

  References Top

1.Al-Sabbagh M. Implants in the esthetic zone. Dent Clin North Am 2006;50:391-407, vi.  Back to cited text no. 1
2.Knoernschild KL. Early survival of single-tooth implants in the esthetic zone may be predictable despite timing of implant placement or loading. J Evid Based Dent Pract 2010;10:52-5.  Back to cited text no. 2
3.Kois JC. Predictable single tooth peri-implant esthetics: Five diagnostic keys. Compend Contin Educ Dent 2001;22:199-206.  Back to cited text no. 3
4.Kois JC, Kan JY. Predictable peri-implant gingival aesthetics: Surgical and prosthodontic rationales. Pract Proced Aesthet Dent 2001;13:691-8.  Back to cited text no. 4
5.Rodriguez AM, Rosenstiel SF. Esthetic considerations related to bone and soft tissue maintenance and development around dental implants: Report of the Committee on Research in Fixed Prosthodontics of the American Academy of Fixed Prosthodontics. J Prosthet Dent 2012;108:259-67.  Back to cited text no. 5
6.Graiff L, Vigolo P. Replacement of a hopeless maxillary central incisor: A technique for the fabrication of an immediate implant-supported interim restoration. Quintessence Int 2012;43:273-7.  Back to cited text no. 6
7.Harvey BV. Optimizing the esthetic potential of implant restorations through the use of immediate implants with immediate provisionals. J Periodontol 2007;78:770-6.  Back to cited text no. 7
8.Lazzara RJ. Immediate implant placement into extraction sites: Surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9:332-43.  Back to cited text no. 8
9.Grütter L, Belser UC. Implant loading protocols for the partially edentulous esthetic zone. Int J Oral Maxillofac Implants 2009;24 Suppl:169-79.  Back to cited text no. 9
10.Gougaloff R, Stalley FC. Immediate placement and provisionalization of a dental implant utilizing the CEREC 3 CAD/CAM Protocol: A clinical case report. J Calif Dent Assoc 2010;38:170-3, 176-7.  Back to cited text no. 10
11.Brown SD, Payne AG. Immediately restored single implants in the aesthetic zone of the maxilla using a novel design: 1-year report. Clin Oral Implants Res 2011;22:445-54.  Back to cited text no. 11
12.den Hartog L, Raghoebar GM, Stellingsma K, Vissink A, Meijer HJ. Immediate non-occlusal loading of single implants in the aesthetic zone: A randomized clinical trial. J Clin Periodontol 2011;38:186-94.  Back to cited text no. 12
13.Fu PS, Wu YM, Tsai CF, Huang TK, Chen WC, Hung CC. Immediate provisional restoration of a single-tooth implant in the esthetic zone: A case report. Kaohsiung J Med Sci 2011;27:80-4.  Back to cited text no. 13
14.Horwitz J, Machtei EE. Immediate and delayed restoration of dental implants in patients with a history of periodontitis: A prospective evaluation up to 5 years. Int J Oral Maxillofac Implants 2012;27:1137-43.  Back to cited text no. 14
15.Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of implants following tooth extraction: Review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19:12-25.  Back to cited text no. 15
16.Zeren KJ. Minimally invasive extraction and immediate implant placement: The preservation of esthetics. Int J Periodontics Restorative Dent 2006;26:171-81.  Back to cited text no. 16
17.Evian CI, Waasdorp JA, Ishii M, Mandracchia M, Sanavi F, Rosenberg ES. Evaluating extraction sockets in the esthetic zone for immediate implant placement. Compend Contin Educ Dent 2011;32:e58-65.  Back to cited text no. 17
18.Hämmerle CH, Araújo MG, Simion M, Osteology Consensus Group 2011. Evidence-based knowledge on the biology and treatment of extraction sockets. Clin Oral Implants Res 2012;23 Suppl 5:80-2.  Back to cited text no. 18
19.De Rouck T, Collys K, Cosyn J. Single-tooth replacement in the anterior maxilla by means of immediate implantation and provisionalization: A review. Int J Oral Maxillofac Implants 2008;23:897-904.  Back to cited text no. 19
20.Cosyn J, Eghbali A, De Bruyn H, Collys K, Cleymaet R, De Rouck T. Immediate single-tooth implants in the anterior maxilla: 3-year results of a case series on hard and soft tissue response and aesthetics. J Clin Periodontol 2011;38:746-53.  Back to cited text no. 20
21.Chu SJ, Salama MA, Salama H, Garber DA, Saito H, Sarnachiaro GO, et al. The dual-zone therapeutic concept of managing immediate implant placement and provisional restoration in anterior extraction sockets. Compend Contin Educ Dent 2012;33:524-32, 534.  Back to cited text no. 21
22.Hürzeler MB, Fickl S, Zuhr O, Wachtel H. Clinical failures and shortfalls of immediate implant procedures. Eur J Esthet Dent 2006;1:128-40.  Back to cited text no. 22
23.Beitlitum L, Artzi Z, Tsesis I, Nemcovsky CE. Clinical dilemmas concerning immediate implants in the esthetic zone. Refuat Hapeh Vehashinayim 2011;28:20-30, 77.  Back to cited text no. 23
24.Tortamano P, Camargo LO, Bello-Silva MS, Kanashiro LH. Immediate implant placement and restoration in the esthetic zone: A prospective study with 18 months of follow-up. Int J Oral Maxillofac Implants 2010;25:345-50.  Back to cited text no. 24
25.Saadoun AP. Immediate implant placement and temporization in extraction and healing sites. Compend Contin Educ Dent 2002;23:309-12, 314-6.  Back to cited text no. 25
26.Lau SL, Chow J, Li W, Chow LK. Classification of maxillary central incisors-implications for immediate implant in the esthetic zone. J Oral Maxillofac Surg 2011;69:142-53.  Back to cited text no. 26
27.Huynh-Ba G, Pjetursson BE, Sanz M, Cecchinato D, Ferrus J, Lindhe J, et al. Analysis of the socket bone wall dimensions in the upper maxilla in relation to immediate implant placement. Clin Oral Implants Res 2010;21:37-42.  Back to cited text no. 27
28.Watanabe T, Marchack BW, Takei HH. Creating labial bone for immediate implant placement: A minimally invasive approach by using orthodontic therapy in the esthetic zone. J Prosthet Dent 2013;110:435-41.  Back to cited text no. 28
29.Grunder U. Crestal ridge width changes when placing implants at the time of tooth extraction with and without soft tissue augmentation after a healing period of 6 months: Report of 24 consecutive cases. Int J Periodontics Restorative Dent 2011;31:9-17.  Back to cited text no. 29
30.Fagan MC, Owens H, Smaha J, Kao RT. Simultaneous hard and soft tissue augmentation for implants in the esthetic zone: Report of 37 consecutive cases. J Periodontol 2008;79:1782-8.  Back to cited text no. 30
31.Dene L, Condos S. Ridge expansion and immediate implant placement in the esthetic zone. N Y State Dent J 2010;76:28-31.  Back to cited text no. 31
32.Kumar NS, Sowmya N, Mehta DS, Kumar PS. Minimal guided bone regeneration procedure for immediate implant placement in the esthetic zone. Dent Res J (Isfahan) 2013;10:98-102.  Back to cited text no. 32
33.Paolantonio M, Dolci M, Scarano A, d'Archivio D, di Placido G, Tumini V, et al. Immediate implantation in fresh extraction sockets. A controlled clinical and histological study in man. J Periodontol 2001;72:1560-71.  Back to cited text no. 33
34.Petrungaro PS. An update on implant placement and provisionalization in extraction, edentulous, and sinus-grafted sites. A clinical report on 3200 sites over 8 years. Compend Contin Educ Dent 2008;29:288-94, 296, 298-300.  Back to cited text no. 34
35.Bruno V, Badino M, Sacco R, Catapano S. The use of a prosthetic template to maintain the papilla in the esthetic zone for immediate implant placement by means of a radiographic procedure. J Prosthet Dent 2012;108:394-7.  Back to cited text no. 35
36.Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol 2001;72:1364-71.  Back to cited text no. 36
37.Gottesman E. Periodontal-restorative collaboration: The basis for interdisciplinary success in partially edentulous patients. Compend Contin Educ Dent 2012;33:478-82.  Back to cited text no. 37
38.Kan JY, Rungcharassaeng K. Proximal socket shield for interimplant papilla preservation in the esthetic zone. Int J Periodontics Restorative Dent 2013;33:e24-31.  Back to cited text no. 38
39.Kan JY, Rungcharassaeng K, Liddelow G, Henry P, Goodacre CJ. Periimplant tissue response following immediate provisional restoration of scalloped implants in the esthetic zone: A one-year pilot prospective multicenter study. J Prosthet Dent 2007;97:S109-18.  Back to cited text no. 39
40.Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman G. Facial gingival tissue stability following immediate placement and provisionalization of maxillary anterior single implants: A 2- to 8-year follow-up. Int J Oral Maxillofac Implants 2011;26:179-87.  Back to cited text no. 40
41.Mankoo T. Maintenance of interdental papillae in the esthetic zone using multiple immediate adjacent implants to restore failing teeth - A report of ten cases at 2 to 7 years follow-up. Eur J Esthet Dent 2008;3:304-22.  Back to cited text no. 41
42.Hartlev J, Kohberg P, Ahlmann S, Gotfredsen E, Andersen NT, Isidor F, et al. Immediate placement and provisionalization of single-tooth implants involving a definitive individual abutment: A clinical and radiographic retrospective study. Clin Oral Implants Res 2013;24:652-8.  Back to cited text no. 42
43.De Rouck T, Collys K, Cosyn J. Immediate single-tooth implants in the anterior maxilla: A 1-year case cohort study on hard and soft tissue response. J Clin Periodontol 2008;35:649-57.  Back to cited text no. 43


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