Immediate Implants

DEPARTMENT OF PROSTHODONTICS & CROWN AND BRIDGE & ORAL IMPLANTOLOGY, DDCH, UDAIPUR
Presented by:
Dr. Jehan Dordi
3rd Yr. MDS
IMMEDIATE IMPLANTS
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CONTENTS
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 Terminologies
 Introduction
 Implant treatment options at the extraction site
 Timing for immediate implants
 Indications of immediate implants
 Contraindications of immediate implants
 Advantages of immediate implants
 Disadvantages of immediate implants
 Rule of 5 triangles

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 Deciding factors for immediate implant treatment modality in extraction socket
 Armamentarium required for atraumatic extraction
 Jumping distance or critical space
 Immediate implantation in the extraction socket of anterior maxilla
 Immediate implantation in the extraction socket of anterior mandible
 Immediate implantation in the extraction socket of multi-rooted posterior teeth
 Clinical guidelines for esthetic outcomes when using immediate implant
protocol.
 Hard tissue changes after immediate implant placement
 Soft tissue changes after immediate implant placement

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 Criteria and guidelines for immediate implant placement site
 Risk and complication in immediate implant placement
 Loading options for the immediately inserted implant
 Survival and success rate of immediate implants
 Recent advances: socket shield
 Review of Literature
 Conclusion
 References

TERMINOLOGIES
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Dental Implant:
1. a prosthetic device made of alloplastic material(s) implanted into the oral
tissues beneath the mucosal and/or periosteal layer and on or within the bone
to provide retention and support for a ﬁxed or removable dental prosthesis;
2. a substance that is placed into and/or on the jaw bone to support a ﬁxed or
removable dental prosthesis
Loading:
 Application of a force directly or indirectly onto a dental implant, tooth, or
prosthesis. GPT- 9

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Dental Implant Loading:
 The process of placing axial or tangential force on a dental implant usually
associated with the intentional exposure of the dental implant either at the time
of initial surgical placement of the dental implant or subsequent to surgical
exposure.
 Such forces may come from any of a variety of sources including:
 Intentional and/or unintentional occlusal loading,
 Unintentional forces from the tongue or other oral tissues,
 Food bolus,
 Alveolar/osseous deformation
Glossary of Implant Dentistry – 3. ICOI

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Immediate placement:
 Immediate implant placement, defined as the placement of dental implant
immediately into fresh extraction socket site after tooth extraction.
First stage dental implant surgery:
 The initial surgical procedure in dental implant placement.
Second-stage dental implant surgery:
 For endosteal dental implant surgery, after surgical reﬂection, the occlusal
aspect of the dental implant is exposed, the healing screw is removed, and
either the interim or deﬁnitive dental implant abutment is placed; after these
procedures, the investing tissues are (when needed) sutured.
Glossary of Implant Dentistry – 3. ICOI

INTRODUCTION
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EXTRACTION OF TOOTH / ROOT IMPLANT PLACEMENT IN EXTRACTED SOCKET
IMMEDIATE PLACEMENT
WITH CROWN
(Immediate loading)
Immediate implant placement- Diagrammatic presentation
IMMEDIATE PLACEMENT
WITHOUT CROWN
(Delayed loading)

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 Immediate implantation in the fresh extraction socket has become the treatment
of choice in implant therapy as it offers many advantages over placing the
implant in healed bone.
 The exact time for placing the implant depends on the structural changes of
hard and soft tissue after extraction.
 Following tooth extraction  the resorption processes of the alveolar bony
walls occurs.
 The bundle bone is mainly involved in the resorption process  results in the
loss of buccal bone volume and height.

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 The socket grafting with immediate insertion of the implant into fresh
extraction sites  prevents this resorption.
 The patient benefits from a less invasive and cost effective procedure resulting
in reduced overall treatment time and higher patient comfort.
 Immediate implantation requires primary stability.
 The possibility of placing an immediate implant depends on the defect anatomy
 therefore a final decision is made at the time of extraction.

IMPLANT TREATMENT OPTIONS AT THE
EXTRACTION SITE
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Buser D, Chappuis V, Belser UC, Chen S. Implant placement post extraction in tooth sites: when immediate, when early, when late?.
J Periodont 2017;73(1):84-102.

Option 1 – Extraction and delayed implant insertion in the healed socket
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 The tooth is extracted and the socket is left to heal for 6–8 weeks before implant
insertion with or without simultaneous guided bone regeneration.
IMPLANT PLACEMENT AFTER SEQUENTIAL DRILLING SUBMERGED IMPLANT
SECOND STAGE SURGERY FOR IMPRESSION & ABUTMENT PLACEMENT
IMPLANT WITH ABUTMENT & FINAL CROWN

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Indications:
 Tooth with the active infection.
 Osseous topography of the extraction socket not favorable.
 Inadequate bone volume apical to the extraction socket to adequately stabilize
the implant.
 Inadequate band of thick, stable, and keratinized marginal tissue around the
extraction socket.

Option 2 – Extraction, socket grafting, and delayed implant insertion in
healed socket
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 The tooth is extracted and the socket is grafted using appropriate bone
substitute to regenerate the adequate bone dimensions at the extraction site.
 The grafted socket is left to heal for 4–6 months before implant insertion.

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Indications:
 Tooth without any active infection.
 Large osseous defect.
 Inadequate bone volume apical to the extraction socket to adequately stabilize
the implant.
 Inadequate band of thick, stable, and keratinized marginal tissue around the
extraction socket.

Option 3 – Extraction and immediate implant insertion with submerged
healing
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 Immediate implantation in the extraction socket is performed with or without
simultaneous bone grafting and covered with the soft tissue flap for submerged
healing.
 The site is re-exposed to uncover and restore the implant after 3–4 months.
Immediate Implant Placement Implant Submerged for Healing

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Indications:
 Osseous topography of the extraction socket is favorable (small or no osseous
defect).
 Adequate bone volume apical to the extraction socket.
 Adequate zone of thick, stable, and keratinized marginal soft tissue around the
extraction socket.
 The inserted implant achieves adequate primary stability (20–25 Ncm).

Option 4 – Extraction and immediate implant insertion with
non-submerged/open healing
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 The dental implant is immediately inserted in the extraction socket and a
gingival former, emerging out of the soft tissues, is placed on top of the implant
and the flap is sutured around it.
 The site is left to heal for 4 to 6 months before the implant is restored.

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Indications:
 Osseous topography of the extraction socket is favorable.
 Adequate bone volume apical to the extraction socket.
extraction socket.
 The coronal advancement of the flap to achieve primary closure may result in
shifting of thick, stable, and keratinized marginal soft tissue to the ridge crest.
 The inserted implant achieves adequate primary stability (30–35 Ncm).

Option 5 – Immediate implantation with nonfunctional loading of the implant
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 The implant is immediately inserted in the extraction socket and a provisional
prosthesis is fixed over the implant, and flap is sutured around it.
 The prosthesis is kept out of occlusion (nonfunctional loading), which is
replaced with a definitive prosthesis, in functional occlusion, after 3–4 months.

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Indications:
 Tooth in the aesthetic region.
 Osseous topography of the extraction socket is favorable for immediate implant
insertion.
 Adequate bone volume apical to the extraction socket to stabilize the implant.

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extraction socket.
 The coronal advancement of the flap to achieve primary closure can result in
 The inserted implant achieves adequate primary stability (>35 Ncm).

Option 6 – Immediate insertion with functional loading of the implant
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 The implant inserted in the extraction socket of low stress, aesthetic region and
achieves higher bone-implant surface percentage and primary stability (more
than 35 Ncm) or,
 Multiple implants are immediately inserted in the extraction sockets with high
primary stability and a splinted provisional prosthesis, in functional occlusion,
is immediately fixed over these implants, which is later replaced with a long-
term definitive prosthesis after the soft tissue is healed in 2–3 weeks.

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Indications:
 Area of low occlusal forces such as aesthetic region and that achieves adequate
BIC percentage and primary stability, e.g. long implant in the maxillary anterior
tooth socket, stabilized in the high density nasal floor, long implant in the
mandibular anterior tooth socket stabilized in the high-density basal bone.
 Multiple teeth without any active infection in the aesthetic region.
 ‘All-on-4’/‘All-on-6’ implant technique done with immediate implantation.
 Multiple implants in extraction sockets with immediate full-arch restoration.
 Immediate implantation with implant overdenture, immediately delivered.

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 Osseous topography of the extraction sockets is favorable.
 Adequate bone volume apical to the extraction sockets.
extraction sockets.
 The coronal advancement of the flap to achieve primary closure can result in
 The inserted implants achieve high primary stability (more than 35 Ncm).

TIMING OF IMPLANT PLACEMENT
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 The timing of implant placement was classified as defined by Hammerle et al:
 Type 1: Immediate implant placement in tooth extraction socket
 Type 2: Early implant placement with soft-tissue healing
 Type 3: Early implant placement with partial bone healing
 Type 4: Delayed implant placement.
Hämmerle CH, Araújo MG, Simion M, Osteology Consensus Group 2011. Evidence‐based knowledge on the biology an treatment of extraction sockets. Clinical oral implants research. 2012 Feb;23:80-2.

INDICATIONS FOR IMMEDIATE PLACEMENT
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 Grossly decayed, nonrestorable, asymptomatic tooth.
 Traumatic loss of tooth with minimum bone loss.
 Horizontal/vertical fracture of teeth
 Periodontally compromised tooth without purulent exudate, which needs
extraction and replacement.
 Inability to perform and complete endodontic treatment.
 Residual deciduous teeth
Agarwal DS, Devkar ND, Vibhute AR, Walke PD. Immediate placement of dental implants: An overview. J Dent Allied Sci 2018;7:70-4.
Amine M, El Kholti W, LaalouY, Bennani A, Kissa J. Immediate Implant Placement: A Review. J Dent Forecast. 2018; 1(2): 1013.

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 Adequate healthy bone volume apical to the extraction socket to stabilize the
implant apex. Most authors recommend the presence of at least 3 to 5 mm of
residual bone beyond the apex and a minimum bone height of 10mm for
primary implant stability.
 Adequate band of thick, stable, and keratinized marginal tissue.
 Extraction socket is favorable for implant insertion at the correct position and
axis for final prosthesis.
 Extraction socket with small or no osseous defect, where adequate bone–
implant surface contact percentage can be achieved and simultaneous bone
grafting for the defect is possible with predictable outcome.

CONTRAINDINCATIONS FOR
IMMEDIATE PLACEMENT
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Henry PJ, Liddelow GJ. Immediate loading of dental implants. Aust Dent J 2008;53:S69-81.

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 Extraction socket possesses large osseous defect
 Inadequate bone volume apical to the extraction socket to stabilize the implant
apex.
 Inadequate band of thick, stable, and keratinized marginal soft tissue around the
socket.
 Extraction socket is unfavorable for implant insertion at the correct position and
axis for final prosthesis.
 The dimensions of the socket are unfavorable for the planned implant
dimensions.
 Placement of implant outside alveolar envelop.

ADVANTAGES OF IMMEDIATE
IMPLANTS
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 Tooth angulations, i.e., ideal implant location mesiodistally and buccolingually
can be attained provided that the extracted tooth has a desirable alignment,
crown length is in harmony with the adjacent teeth, natural scalloping and
distinct papilla are easier to achieve and there is maximal soft tissue support.
 Preservation of bone at the extraction site.
 Optimal soft tissue esthetics may be achieved.
Tadikonda DC, Pagadala S. Immediate implant placement—a review. Sch. J. Dent. Sci.. 2015;2:296.

DISADVANTAGES OF IMMEDIATE
IMPLANTS
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 Increased risk of infection to the implant.
 Less initial bone-to-implant contact (BIC) percentage.
 Grafting required, filling voids and spaces.
 Loss of marginal keratinized soft tissue collar, if flap is released and coronally
advanced to achieve primary closure.
 Difficulty in achieving soft tissue closure.
Amine M, El Kholti W, LaalouY, Bennani A, Kissa J. Immediate Implant Placement: A Review. J Dent Forecast. 2018; 1(2): 1013.

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 Micro-movement of implant with low primary stability during its healing
phase.
 Technique-sensitive procedure with less control during drilling.
 Offset implant insertion, if implant is inserted in one of the root sockets of
multi-rooted tooth.
 Increased cost of the treatment, if grafting materials and collagen barrier
membrane are used.

THE RULE OF 5 TRIANGLES
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 To achieve excellence when placing immediate implants, there are 5 key
aspects to consider during the decision making process, to help prevent
blunders that can lead to difficult esthetic situations. The following are:
1. The presence of a buccal plate,
2. Primary stability,
3. Implant design,
4. Filling of the gap between the buccal plate and the implant, and
5. Tissue biotype

DECIDING FACTORS FOR IMMEDIATE IMPLANT
TREATMENT MODALITY IN EXTRACTION SOCKET
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Zitzmann NU, Krastl G, Hecker H, Walter C, Waltimo T, Weiger R.
Strategic considerations in treatment planning: deciding when to treat, extract, or replace a questionable tooth.
J Prosthet Dent. 2019;104(2):80-91.

1. Osseous Topography of Extraction Socket (Bone Defect)
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 Bone defects can be of different types and sizes.
 The mode of implant therapy largely depends on the number of intact bony
walls the extraction socket contains.

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Favorable small to medium osseous defect:
 These are osseous defects where the implant can immediately be inserted within
the bony envelope and the osseous defect can successfully be grafted with
predictable outcome.
Unfavourable small to medium osseous defect:
 The osseous defect, where the implant cannot immediately be inserted within
the bony envelop and the bony walls do not provide adequate space for guided
bone regeneration.

2. Bone Dimensions (Height & Width)
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 Treatment modality largely depends on
 The bone dimensions of the socket
 The available bone volume apical to the socket to engage the widest and
longest possible implant with adequate initial stability and BIC percentage.
 A minimum 3–5 mm of bone height apical to the extraction socket, should be
available to adequately engage the implant apex.
 If any non-infected periapical lesion related to extracted tooth is present, the
implant should further be engaged 3–5 mm apical to that radiolucent lesion.

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(A–C) The apex of the implant should be engaged
into 3–5 mm healthy bone apical to the extraction
socket to achieve adequate primary stability.
(A and B) If any non-infected periapical
cyst/radiolucency related to the extracted tooth is
present, the implant should further be engaged 3–
5 mm apical to the radiolucent area.

3. Bone Density
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 The density of the bony walls and bone apical to the socket  plays a key role
in achieving primary stability.
 An implant inserted in the extraction socket achieves less BIC percentage when
compared to the implant inserted in the healed socket.
 If the bone density in the socket area is low  adequate primary stability of the
implant can be a challenge  lead to micro-movements of the implant during
its healing phase  subsequent failure.

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 To overcome this complication, the implant surgeon should follow the
following guidelines when inserting the implant in the extraction socket in the
areas of low-density bone:
 Placing widest and longest possible implant to achieve maximum area of
contact between the bone and implant surface.
 Using an implant with deeper threads and with high pitch value to engage
maximum bone and achieve adequate primary stability.

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 Bone condensing using osteotomes.
 Submerging the implant platform 1–2 mm apical to the bone crest to avoid
micro-movement under occlusal forces
 Bicortical engagement of the implant.
 Using implant with the fast osseointegrating surfaces (e.g. SLA surface,
anodized surface, etc.).

4. Occlusal forces
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 The implants inserted in the extraction sockets of anterior regions usually can
immediately be restored with nonfunctional loading.
 The occlusal forces in this region are very low, compared to the posterior
segments.
 The immediate restoration/loading of the single implant should be avoided in
the posterior segment.

5. Primary stability of dental implant
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 The mode of implant therapy in the extraction socket largely depends on the
primary stability of the implant inserted in the fresh extraction socket.
 Primary stability < 25 Ncm: The implant should be submerged for closed
healing to avoid micromovement during the phase of osseointegration.
 Primary stability between 25 and 35 Ncm: Open or nonsubmerged healing
protocol with immediately placed healing abutment/gingival former on top of
implant can be preferred.
 Primary stability > 35 Ncm: The implant can immediately be restored with the
nonfunctional (out of occlusion) loading in the aesthetic region.

6. Region
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Aesthetic region: Immediate restoration of aesthetics may be the treatment of
choice in the aesthetic region.
 If the post-implantation situation is favorable for open healing and immediate
restoration (nonfunctional)  a provisional prosthesis can immediately be
placed over the implant.
 For closed healing protocol for the inserted implant  a resin-bonded or soft
tissue-supported provisional prosthesis (to restore aesthetics during healing.)
Non-aesthetic region: Immediate restoration, even nonfunctional, should be
avoided to avoid any micromovement of the implant during the phase of its
osseointegration.

7. Situation of Soft Tissues
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1. Biotype:
 Thick biotype:
 Thick soft tissue biotypes  more resistant to recessions and infection and are hence
the best for any kind of implant insertion.
 Thin biotype:
 Thin biotype  less resistant to recession and peri-implant infections (peri-implantitis);
hence restoration of this biotype should be done before choosing the open or closed
implant healing protocols.
 Connective tissue grafting to change thin biotype  thick biotype at the stage of
uncovery of the implant or before prosthetic procedures.

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2. Soft tissue collar:
Keratinized:
 Plan to achieve minimum 3–4 mm thick, stable, and keratinized marginal soft tissue collar
around the implant prosthesis
 Provides resistance  muscle pull, recession, and peri-implantitis.
Non-keratinized:
 If a thin, mobile, and non keratinized marginal soft tissue collar around the socket  the
extraction and delayed implant insertion.
 If planned to immediately insert the implant into the fresh extraction socket  perform the
soft tissue grafting with the implant insertion or at the time of implant uncover  to
regenerate a thick, stable, and keratinized marginal soft tissue collar around the final
prosthesis.

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3. Interdental papilla:
Intact papilla:
 The implant should be inserted immediately and a provisional prosthesis should
be placed to support the papilla.
 If the implant cannot be immediately restored, provisional prosthesis bonded to
the adjacent teeth must be given to support the intact papillae.
Compromised or missing papilla:
 The implant can be inserted with the submerged technique.
 The papillae, if lost can be re-formed with various techniques at the time of
implant uncovery.

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4. Primary closure of soft tissue after extraction and implant insertion
 If achieving the primary closure of the soft tissue is difficult and the clinical
situation of implant is not favorable for non-submerged healing  harvest a
thick epithelialized connective tissue graft from the patient’s palate and suture
over the inserted submerged implant.
 Alternatively, the non-resorbable cytoplast barrier membrane to cover the
socket opening can be used.
 This membrane can be left exposed in the oral cavity and immobilized by
figure of eight sutures.

8. Implant Selection
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Tapered implant:
 For immediate implant placement  initial fixation is very important because
the contact area between fixture and bone is inevitably small.
 A tapered implant which has excellent initial fixation is more favorable than
the parallel body implants.
The implant with deeper threads with high pitch value, and sharp cutting blades at the apex should be preferred in
immediate implantation cases to achieve adequate primary stability. (A–D) The sharp cutting blades at the implant
apex also help in directing the implant to the correct three-dimensional positions during insertion

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The implant with self-tapping/self-cutting, deeper threads at the apex:
 Preferred for immediate implantation cases  achieves high initial
anchorage/stability in the small amount of healthy bone present apical to the
extraction socket.
Wide implants:
 Select a diameter capable of minimizing the gap between the implant surface
and socket walls  favorable initial fixation and does not require guided bone
generation.

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Back tapered coronal design (platform shifting/switching):
 Implants which has the reverse coronal thread design are preferred for
immediate implant  it avoids the pressure against the thin bony crest margins
of the extraction socket, which may result in crestal bone resorption.
 It allows a stress-free environment at the crestal region for clot formation and
the regeneration of a good amount of hard and soft tissue around its reverse
coronal part.
 This not only prevents crestal bone resorption but also permits the formation of
thick soft tissue at the crest resulting in high soft tissue aesthetic around the
final prosthesis.

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Implant surface:
 The implants with bioactive surfaces should be preferred, as several studies
have shown these surfaces to have the property of early and enhanced
osseointegration, thereby increasing the predictability of treatment in immediate
implant cases.

9. Oral Hygiene
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 Oral hygiene of the patient should be improved before implant insertion in the
extraction socket by scaling, root planing, etc.
 For patients with compromised oral hygiene, the closed healing protocol
should be preferred to avoid any post-implantation infection.

10. Aesthetic and functional demands
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 If conditions are favorable  the immediate implant preferred in the aesthetic
region.
 Immediately restored (nonfunctional) to fulfil the aesthetic demands of the
patient.
 If the implant does not achieve adequate primary stability (more than 35 Ncm)
 submerged healing, and a fixed prosthesis bonded to the adjacent teeth can
be given for the aesthetic purposes.

11. Number of Implants
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 Single-tooth replacement – check if other factors are favorable.
 Multiple teeth replacement – In the case of multiple implants, if immediate
functional or nonfunctional restoration is planned, then all the implants should
be splinted together using a rigid prosthesis to minimize the micro-movements
of the implants during function.

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 The implant surgeon should have the armamentarium for atraumatic extraction
to preserve the hard and soft tissue architecture of the socket for ideal implant
placement.
 The implant surgeon needs to have the set of periotomes and luxators for
atraumatic extraction.
 The special extraction kit of the piezotome, offers several advantages for
atraumatic extraction.

ARMAMENTARIUM REQUIRED FOR
ATRAUMATIC EXTRACTION
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Periotomes for atraumatic extraction of the tooth planned for
immediate implantation.
Luxators is highly recommended for
atraumatic extraction of the tooth
planned for immediate implantation.

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(C) The piezotome with (D) its special extraction kit offers several advantages
for atraumatic extraction of the tooth planned for immediate implantation

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Benex extractor Benex kit

JUMPING DISTANCE OR CRITICAL SPACE
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 Following tooth extraction  a socket presents dimensions considerably
greater than the diameter of implant.
 Sockets are oval and tapered along their length, whereas implants are round.
 Due to this geometric discrepancy the implant may not completely fill the
extraction socket.

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 Hence, following implant installation  a gap may occur in the marginal
part of the recipient site.
 This distance is called the ‘jumping distance of osseointegration’.
 Any space between implant surfaces and the socket wall which is > 2 mm
 soft tissue ingrowths, and hence need to be grafted.
 If the space is < 2 mm  the bone will grow to fill the space.

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Extraction socket seal classification by Krauser and Hahn

IMMEDIATE IMPLANTATION IN THE EXTRACTION
SOCKET OF ANTERIOR MAXILLA
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(A)The extraction socket of the pre-maxillary region often shows a thin facial cortical plate, which is prone to
perforation/dehiscence during implant osteotomy preparation because the drill tends to slip away from the hard
palatal cortical bone towards the thin facial plate.
(B)To overcome this problem the osteotomy preparation should be started with the drilling slightly towards the
hard palatal cortex using a pilot drill, which should reach minimum 4–5 mm deep apical to the extraction
socket.

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(A–D) All the osteotomy widening drills are used to the same direction and depth, keeping away from the thin
facial plate. During drilling, the three-dimensional orientation of the final implant position should also be
visualized.

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(A)Once the osteotomy has been prepared, either the
autogenous bone, collected from the drills, or
(B)the bone substitute is used to reinforce the thin
facial plate.
(C)This is followed by implant placement at the correct
position and axis.
(D)(D and E) If implant has achieved adequate primary
stability, a transmucosal abutment (gingival former)
is inserted on top of implant and soft tissue, if
required, is sutured around the same.
(E)(F) The grafting against the thin facial plate
ultimately resulted in regeneration of thick bone
facial to the implant collar.

IMMEDIATE IMPLANTATION IN THE EXTRACTION
SOCKET OF ANTERIOR MANDIBLE
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 The bone in the mandibular anterior region is usually found adequate in height
and density to insert long implants with good primary stability.
 Hence, usually can be immediately restored to fulfil the aesthetic and
functional demands of the patient.

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 There are many advantages in this region, which facilitate immediate
implantation with immediate loading:
 No anatomical structures which can hinder placement of implants.
 Longest (16–18 mm long) implants can be inserted to achieve a high initial
stability.
 Long implant can be stabilized in high density basal bone.
 Less number of the implants can be inserted to support a multiple unit bridge,
4–6 unit bridge over two implants.

IMMEDIATE IMPLANTS IN EXTRACTION SOCKETS
OF MULTIROOTED POSTERIOR TEETH OF
MAXILLAAND MANDIBLE
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 Less common than immediate implants in anterior region.
 The main reason is the topography of the resultant extraction socket, which is
two-rooted in mandibular and 3-rooted in the maxillary molar area.
 When planning immediate implant in the extraction socket of a multirooted
tooth, the implant surgeon may choose one of the two protocols:

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Protocol 1:
 Implant insertion in any one of the root sockets. The choice of the root socket
depends on a few anatomical and radiographic features of the particular root
socket.
 The following socket types should be preferred:
 Socket with more intact osseous topography (minimum or no wall defects)
 Socket more close to the mesiodistal midpoint between two adjacent teeth; it avoids
cantilevered forces on the inserted implant.
 The disadvantage of this protocol is that it may results in off-axis implant
placement, which may result in a large amount of cantilevered forces on the
inserted implant.

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(A) Post-extraction socket of the mandibular molar poses two root sockets, and
(B) (B and C) if the implant is inserted in one of the extraction sockets, it may result in offset
(cantilevered) forces on the implant once it finally restored in function.
(C) (D) Ideally, the implant should be inserted at the midpoint of mesiodistal dimensions
between two adjacent teeth but are often inserted at the interradicular septal region, to
avoid the offset forces on the implant prosthesis.

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Protocol 2:
 The implant insertion at the ideal position (into inter-radicular septal region).
 Step by step diagrammatic presentation of immediate implant in multirooted
tooth socket.

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(A)Atraumatic extraction of multirooted tooth is done and
(B) the osteotomy preparation begins using a sharp pointed drill in the region of the
interradicular septa.
(C) Alternatively, one can use a trephine drill to prepare the implant osteotomy and to remove
interradicular septa which can be used to graft the post-implantation peri-implant socket
spaces.

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Further, the osteotomy is prepared 3–5 mm apical to the extraction socket
using all implant drills to engage the implant apex in the healthy dense bone
and to achieve adequate primary stability of the implant .

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A) The implant is inserted into the septal region and the peri-implant socket spaces are grafted using autogenous
bone alone or mixed with bone substitute.
B) For large grafted spaces, a barrier membrane should be used to cover the socket and
C) the flap is sutured back for submerged implant healing, for a minimum of 4 months.
D) Implant is uncovered after 4 months and restored with an ideal prosthesis which has the entire occlusal load
along the implant axis.

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Trepan technique
b1,b2: Bone graft harvesting using a trepan;
b3:Implant drilling;
b4: Implant placement;
b5: Bone graft placement between the implant and buccal bone socket.

CLINICAL GUIDELINES FOR ESTHETIC OUTCOMES
WHEN USING IMMEDIATE IMPLANT PROTOCOL.
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 Thick and intact buccal bone wall
 Thick gingival biotype
 Minimal trauma in tooth extraction
 Presence of at least 3 socket walls—ideally 4 walls
 Implant shoulder should be placed 2–3 mm apical to anticipated gingival
margin.
Javaid MA, Khurshid Z, Zafar MS, Najeeb S. Immediate implants: clinical guidelines for esthetic outcomes. Dentistry journal. 2016 Jun;4(2):21.

91
 Primary implant stability with engagement of 3–4 mm bone apical to root
apex.
 Slight palatal/lingual positioning of implant.
 Fill the gap between implant and inner bone surface using a low resorbing
bone graft material with or without membrane.

HARD TISSUE CHANGES AFTER
IMMEDIATE IMPLANT PLACEMENT
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 Botticelli et al. reported that the buccal bone plate undergoes more than 50%
reduction in horizontal dimensions following placement of single unit
immediate implant in maxilla.
 The authors also reported a mean vertical bone loss of 1 mm that was
accentuated in the presence of a thin buccal wall and placement of implants in
anterior maxilla.
 Multivariate analyses revealed that the thickness of buccal bone wall was a key
factor influencing horizontal bone resorption changes. Similarly, vertical
changes were significantly influenced by implant position and the thickness of
buccal bone wall.

SOFT TISSUE CHANGES AFTER
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Factors that influence marginal tissue recession include:
 Position of implant, with greater recession being a common occurrence when
the implants were positioned buccally.
 Gingival biotype—increased recession was observed in cases with thin
biotype.
 Similar results were reported by Chen et al. demonstrating at least 1 mm
recession in over 30% of the sites after 18 months of follow up period. The
authors also reported significant association between marginal recession and
position of implant in relation to buccal bone plate.
 Recession was seen in 16.7% of the implants placed lingually as compared to
58.3% of the buccally placed immediate implants.

CRITERIA FOR IMMEDIATE IMPLANT
PLACEMENT SITE
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 Not all extraction sites lend themselves to immediate implantation. Careful
evaluation based on clinical guidelines must direct the clinician as to the
suitability of the socket and the appropriate surgical procedures.
 A group of researchers have proposed a pre-operative classification of
extraction sites based on the classical definition of periodontal intrabony
defects.
 They divided the extraction sites into three types, each possessing distinctive
characteristics:

Type 1 extraction site:
98
 The type 1 site is an incipient defect environment with a good regenerative
potential and an acceptable esthetic prognosis.
 The environment is dominated by the four-wall socket or the incipient three–
wall dehiscence type defect (5mm or less in the apico coronal direction). The
osseous crests lie in the coronal third of the root to be extracted.
 Adequate bone is available (i.e. 4-6mm) beyond the apex for initial stabilization
of the implant.
6th ITI Guidelines and Consensus statement

99
 A type 2 site is a moderately compromised regenerative and esthetic
environment.
 A moderate defect environment is predominant, and it extends through the
middle third of the root; this includes a dehiscence of greater than 5mm.
 The type 2 extraction environment poses several functional and esthetic
limitations. The reduced regenerative potential of the significant defect
environment may force a more apical and possibly less than ideal placement of
the implant

100
 A type 3 site is a severely compromised environment in which immediate
implant placement is not an option.
 Vertical and buccolingual dimensions of bone are inadequate for placement and
stabilization of the immediate implant.
 Recession is present and loss of labial plate of bone is severe.
 Severe circumferential and angular defects are present.
 Not suitable for immediate implantation owing to inadequate vertical and
buccolingual bone dimension, recession and severe loss of the labial bone plate,
and severe circumferential and angular defects.

RISK AND COMPLICATION IN
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COMPLICATIONS AND MANAGEMENT ASSOCIATED WITH IMMEDIATE IMPLANT
COMPLICATION MANAGEMENT
1 Recession long-term stability of the mucosal tissue around the implant can be
ensured by the use of adjunct soft tissue grafting.
2 Poor quality and
insufficient
quantity of bone
Packing of bone graft particulates and simultaneous use of osteotome
transforms very spongy bone into dense
3 Surgical trauma Overheating the bone should be avoided by using copious irrigation
and periodic replacement of twist drills to ensure sharpness
4 Infection Premedication with broad-spectrum antibiotics is recommended.
Thorough debridement of contained infection in the extraction socket
and excavation of all of the soft and granulation tissues are necessary
5 Violation of
anatomic structure
The availability of 3 to 5 mm of bone past the apex of the root is often
necessary for primary stability and is helpful for avoiding the
violation of surrounding anatomic structures.

103
COMPLICATIONS AND MANAGEMENT ASSOCIATED WITH IMMEDIATE IMPLANT
COMPLICATION MANAGEMENT
6 Fenestration and
dehiscence
A resorbable or non-resorbable membrane can be used with or
without bone particulate from various sources
7 Implant stability Primary stability and success of implants are more likely when
implants are supported by cortical bone.
8 Malpositioning of
implant
Correction of integrated malpositioned implants is difficult and
limited to prosthetic correction; otherwise, removal of the implant is
warranted
9 Unaesthetic
outcome
Placing a bone graft and contoured healing abutment or provisional
restoration at the time of flapless implant placement in a post
extraction socket

LOADING OPTIONS FOR THE
IMMEDIATELY INSERTED IMPLANT
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 Conventional loading: The implant is loaded after 3-6 months of subgingival
healing.
 Immediate non-functional: The implant is restored out of occlusion, within 48
h of insertion.
 Immediate loading: The implant is restored in occlusion, within 48 h of
insertion.
 Early loading: The implant is restored in occlusion, after 48 h of insertion and
before 4 months have elapsed.

106
 Delayed loading: The implant is restored after 3 – 6 months.
 Progressive loading: Light contact at first and gradual loading to full
occlusion.
 Good primary stability – torque >35 Ncm
 No excessive micromovement – <100 µ
 Implant length – minimal, 10 mm
 Bone density type – high-density bone (D1 or D2)
 Bicortical anchorage of implant
Criteria for Successful Loading in the Aesthetic Zone

107
 Parafunction – Bruxism
 Low quality bone (Type D4)
 Infected implantation sites
 Large osseous defect
Risk factors for immediate implantation & functional loading
Consensus on immediate loading
 Implant length: >10 mm
 Implant diameter: >3.3 mm
 Implant design: Screw form/tapered
 Implant surface: Rough titanium surface
 Occlusal scheme: No occlusal or lateral forces

SURVIVALAND SUCCESS RATE OF
IMPLANTS PLACEMENT WITH LOADING
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109
 Immediate placement plus immediate restoration/ loading is a clinically
documented protocol. The survival rate was 98%.
 Immediate placement plus early loading is a clinically documented protocol.
The survival rate was 98%.
 Immediate placement plus conventional loading is a scientifically and clinically
valid protocol. The survival rate was 96%.
 Early placement plus immediate restoration/loading presents clinically
insufficient documentation.

110
 Early placement plus early loading presents clinically insufficient
documentation.
 Early placement plus conventional loading is a scientifically and clinically
valid protocol. The survival rate was 96%.
 Delayed placement plus immediate restoration/loading is a clinically
documented protocol. The survival rate was 98%.
 Delayed placement plus early loading is a scientifically and clinically valid
protocol. The survival rate was 98%.

RECENT ADVANCES: SOCKET SHIELD
111

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 In 2010, Hürzeler et al. introduced a new method, the socket shield technique,
in which a partial root fragment was retained around an immediately placed
implant with the aim of avoiding tissue alterations after tooth extraction.
 Preparation of root in such a way that buccal/facial section remains in-situ with
buccal plate intact.
 Tooth root sections and periodontal attachment apparatus remains vital and
undamaged to prevent the expected post extraction socket remodeling and to
support buccal/facial tissues

REVIEW OF LITERATURE
113

Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clinical oral
implants research. 2018;19(1):73-80.
114
 This retrospective review analyzed the esthetic outcomes of 42 non-adjacent
single-unit implant restorations completed using an immediate implant surgical
placement protocol.
 The mean time in function was 18.9 months (range 6–50 months) and the
majority of implants placed had a restorative platform diameter of 4.1 and 4.8
mm.
 Authors concluded that following restoration of immediate implants, a high
incidence and statistically significant recession of the buccal marginal mucosa
(0.9 0.78 mm) occurred after a mean observation period of 19.9 months

115
 A recession of 1 mm or more occurred at 40.5% of sites; only 14.3% of the
sites demonstrated no recession.
 Implants that were positioned with the shoulder at or buccal to a line between
the cervical margins of adjacent teeth showed three times more recession than
sites with implants placed lingual to this line.
 Recession was observed at both thin and thick biotype sites. However,
recession at thin biotype sites tended to be of a greater magnitude.
 There was minimal change to the height of the mesial and distal papillae.

Lee J, Park D, Koo KT, Seol YJ, Lee YM. Comparison of immediate implant placement in
infected and non-infected extraction sockets: a systematic review and meta-analysis. Acta
Odontologica Scandinavica. 2019;76(5):338-45.
116
 This review aimed to investigate the feasibility of immediate implant placement
in infected extraction sockets.
 Authors performed electronic and manual searches up to March 2019 to obtain
data from randomized controlled trials (RCTs) and nonrandomized controlled
clinical trials (CCTs).
 Using a fixed-effects model to assess the difference in survival rate (primary
outcome), authors evaluated the risk difference for immediate implant
placement in infected and non-infected sites.

117
 Authors concluded that the results of meta-analysis suggest that immediate
implant placement in periapically infected extraction sockets is feasible
following cautious debridement and the use of proper surgical protocols.
 In addition, changes in the soft tissue profile and aesthetics should be
considered when performing immediate implant placement in infected sites.

Crippa R, Aiuto R, Guardincerri M, Peñarrocha Diago M, Angiero F. Effect of laser radiation
on infected sites for the immediate placement of dental implants. Photobiomodulation,
photomedicine, and laser surgery. 2020;38(3):186-92.
118
 The study aimed to evaluate the feasibility of erbium-chromium: yttrium-
scandium-gallium-garnet (ErCr:YSGG 2780 nm) laser irradiation on infected
and/or inflamed post-extraction sites for the immediate placement, and when
possible, immediate loading, of endosseous implants.
 Sixty-six patients were included in the study for a total of 94 post-extraction
implants, inserted in the maxilla and mandible. All patients were eligible for
implant therapy, having at least one compromised tooth requiring extraction,
along with sign of inflammation and/or infection.
 Surgery and socket decontamination were performed using an ErCr:YSGG
laser.

119
 To improve bone healing, Bio-Oss and resorbable membrane were used in 57
patients. Eleven implants were immediately loaded, whereas 83 were loaded
within 3–6 months, depending on the extraction site.
 Intraoral radiographs were taken at 1, 3, 6, 9, and 12 months from the implant
placement to assess the alveolar bone level and treatment’s outcome.
 The combination of mechanical, chemical, and laser treatment was proven to be
highly effective for the disinfection of post-extraction sites.
 The ErCr:YSGG laser is a useful tool, not only for its practicality as a surgical
device but also as a disinfection tool, granting optimal results after implant
surgery.

CONCLUSION
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121
 Backed with scientific literature and clinical trials, immediate implantation in
the extraction socket has now been established as a proven implant technique.
 Immediate implant in the aesthetic region offers several advantages over
conventional implant placement in healed socket.
 Immediate implantation cases should be thoroughly planned with study
models, radiographs, and dental CT images, to place the implant at the correct
position in the socket without perforating any socket wall.
 However, the ultimate decision for immediate implant placement is made
during the surgery after tooth extraction.

REFERENCES
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123
 Dental Implants. The Art & Science. Charles Babbush, Jack Hahn, Jack Krauser. 2nd Ed.
2011.
 Glossary of prosthodontic terms. Journal of Prosthetic Dentistry. 2017.
 Glossary of Implant Dentistry – 3. ICOI
 Clinical Implantology. Ajay Vikram Singh. 1st Ed. 2013
 Immediate implant placement: treatment planning and surgical steps for successful
outcomes. W. Becker. British Dental Journal 2006;201(4):199-205.
 Evidence-based Implant Treatment Planning and Clinical Protocols - Steven J. Sadowsky.
2016.
 Immediate implants following tooth extraction - A systematic review. Jordi O, Tania P,
Santiago M, Federico H, Eduard F. Med Oral Patol Oral Cir Bucal. 2012;17(2):251-61.
 Immediate Implant Placement by Interradicular Bone Drilling before Molar Extraction:
Clinical Case Report with One-Year Follow-Up. Stuardo V, Jose M, Nicolas W and Dafna
B. Case Reports in Dentistry. 2016.

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 Amine M, El Kholti W, LaalouY, Bennani A, Kissa J. Immediate Implant Placement: A
Review. J Dent Forecast. 2018; 1(2): 1013.
 Agarwal DS, Devkar ND, Vibhute AR, Walke PD. Immediate placement of dental implants:
An overview. J Dent Allied Sci 2018;7:70-4.
 Henry PJ, Liddelow GJ. Immediate loading of dental implants. Aust Dent J 2008;53 Suppl
1:S69-81.
 Tadikonda DC, Pagadala S. Immediate implant placement—a review. Sch. J. Dent. Sci..
2015;2:296.
 Hämmerle CH, Araújo MG, Simion M, Osteology Consensus Group 2011. Evidence‐based
knowledge on the biology an treatment of extraction sockets. Clinical oral implants research.
2012 Feb;23:80-2.
 Zitzmann NU, Krastl G, Hecker H, Walter C, Waltimo T, Weiger R. Strategic considerations
in treatment planning: deciding when to treat, extract, or replace a questionable tooth. The
Journal of prosthetic dentistry. 2019;104(2):80-91.

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