Implants into fresh extraction site: A literature review, case immediate placement report

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REVIEW ARTICLE

Implants into fresh extraction site: A literature review,
case immediate placement report
Abu-Hussein Muhamad1,2, Abdulghani Azzaldeen3, Sarafi Anou Aspasia4, Kontoes Nikos5
ABSTRACT

Immediate implants are positioned in the course of surgical extraction of the tooth to be replaced.
The percentage success of such procedures varies among authors from 92.7-98.0%. The main
indication of immediate implantation is the replacement of teeth with pathologies not amenable to
treatment. Its advantages with respect to delayed implantation include reduced postextraction alveolar
bone resorption, a shortening of rehabilitation treatment time, and avoidance of a second surgical
intervention. The inconveniences in turn comprise a general requirement for membrane‑guided
bone regeneration techniques, with the associated risk of exposure and infection, and the need for
mucogingival grafts to seal the socket space and/or cover the membranes. The surgical requirements for
immediate implantation include extraction with the least trauma possible, preservation of the extraction
socket walls and thorough alveolar curettage to eliminate all pathological material. Primary stability
is an essential requirement, and is achieved with an implant exceeding the alveolar apex by 3-5 mm,
or by placing an implant of greater diameter than the remnant alveolus. Esthetic emergence in the
anterior zone is achieved by 1-3 mm subcrest implantation. Regarding guided regeneration of alveolar
bone, the literature lacks consensus on the use of membranes and type of filler material required.
While primary wound closure is desirable, some authors do not consider it to be of great relevance.
KEY WORDS: Dental implants, immediate implants, fresh extraction

INTRODUCTION
Immediate implants are defined as the placement of
implants in course of surgical extraction of the teeth to
be replaced. The insertion of implants immediately after
extraction is not new, and in the 1980s, the University of
Tübingen advocated the procedure as the technique of
choice for Tübingen and München ceramic implants.[1,2]
As a result of the success of the protocol designed by
Brånemark and his team for their dental implant system,
University of Napoli, Italy, 2University of Athens, Greece,
Al-Quds University, Jeruslem, Israel, 4University of Athens,
5
Private Practice, Athens, Greece
1
3

Address for correspondence: Dr. Abu‑Hussein Muhamad,
123 Argus street, 10441, Athens‑Greece. E-mail: abuhusseinmuhamad@gmail.com

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DOI:
10.4103/0974-6781.118858

160

other procedures were largely relegated for many years.
Initially, a healing period of 9-12 months was advised
between tooth extraction and implant placement.
Nevertheless, as a result of continued research, a number
of the concepts contained in the Brånemark protocol and
previously regarded as axiomatic; such as the submerged
technique concept, delayed loading, machined titanium
surface, etc.; have since been revised and improved upon
even by actual creators of the procedure.[2‑4]
Based on the time elapsed between extraction and
implantation, the following classification has been
established relating the receptor zone to the required
therapeutic approach:
a. Immediate implantation, when the remnant bone
suffices to ensure primary stability of the implant,
which is inserted in the course of surgical extraction
of the tooth to be replaced (primary immediate
implants)
b. Recent implantation, when approximately 6-8 weeks
have elapsed from extraction to implantation, a
time during which the soft tissues heal, allowing
adequate mucogingival covering of the alveolus
(secondary immediate implants)
Journal of Dental Implants | Jul - Dec 2013 | Vol 3 | Issue 2


Muhamad, et al.: Implants into fresh extraction site

c. Delayed implantation, when the receptor zone is not
optimum for either immediate or recent implantation.
Bone promotion is first carried out with bone grafts
and/or barrier membranes, followed approximately
6 months later by implant positioning (delayed implants)
d. Mature implantation, when over 9 months have
elapsed from extraction to implantation. Mature bone
is found in such situations.[1,3‑7]

INDICATIONS OF IMMEDIATE IMPLANTATION
Primary implantation is fundamentally indicated
for replacing teeth with pathologies not amenable
to treatment, such as caries or fractures. Immediate
implants are also indicated simultaneous to the removal
of impacted canines and temporal teeth.[1,4,7]
Immediate implantation can be carried out on extracting
teeth with chronic apical lesions which are not likely to
improve with endodontic treatment and apical surgery.
et al., in a study in dogs, inserted immediate implants
in locations with Novae’s chronic periapical infection.
These authors reported good results and pointed out
that despite evident signs of periapical disease, implant
placement is not contraindicated if pre‑ and postoperative
antibiotic coverage is provided and adequate cleaning
of the alveolar bed is ensured prior to implantation.[3,4,8]
While immediate implantation can be indicated
in parallel to the extraction of teeth with serious
periodontal problems, Ibbott et al., reported a case
involving an acute periodontal abscess associated
with immediate implant placement, in a patient in the
maintenance phase.[1,4,6‑8]

CONTRAINDICATIONS
The existence of an acute periapical inflammatory
process constitutes an absolute contraindication to
immediate implantation.[4,8,9]
In the case of socket implant diameter, discrepancies in
excess of 5 mm, which would leave most of the implant
without bone contact, prior bone regeneration and
delayed implantation may be considered.[4,8,9]

ADVANTAGES
One of the advantages of immediate implantation
is that post extraction alveolar process resorption
is reduced, thus affording improved functional and
esthetic results.
Another advantage is represented by a shortening in
treatment time, since with immediate placement it is
not necessary to wait 6-9 months for healing and bone

neoformation of the socket bed to take place.[4,9,10] Patient
acceptance of this advantage is good, and psychological
stress is avoided by suppressing the need for repeat
surgery for implantation.[4,7,8]
Preservation of the vestibular cortical component allows
precise implant placement, improves the prosthetic
emergence profile, and moreover preserves the
morphology of the peri‑implant soft tissues; thereby
affording improved esthetic‑prosthetic performance.[8‑10]

SURGICAL CONSIDERATIONS
The surgical criteria which apply to immediate
implantation include the following:
Ensure that extraction is as least traumatic as possible,
to maximize bone integrity. In teeth with multiple roots,
dental sectioning is indicated, with individualized
extraction of the roots. The socket walls are to be
preserved during extraction, particularly the vestibular
wall, the level of which should be harmonized with that
of neighboring teeth, to ensure esthetic emergence of
prosthetic post.[1,3,4,7]
Before positioning the immediate implant, careful
curettage and alveolar cleaning is required to remove
any trace of infected or inflamed tissue, together with
remains of the periodontal ligament.[2,7‑9]
The implant must possess sufficient primary stability.
This is generally ensured by exceeding the apex by
3-5 mm, or by using an implant of greater diameter than
the socket.[1,5]

Implant placement

In anterior teeth, the ideal orientation of implant axis
does not usually correspond to that of the socket. Implant
placement in the direction of root would oblige vestibular
emergence of retention screw or use of prosthetic
additaments for the change in angle. The implant bed
is to be prepared palatal, and osteodilators can be used
to this effect. In the molar region of the upper jaw, it is
preferable to establish fixation in the palatal root, since
the buccal counterparts are covered by a fine bone layer.
In the posterior mandibular region, the inferior alveolar
neurovascular bundle often lies very close to the apexes
of premolars and molars, and roots of the latter tend to
be large; thereby precluding adequate primary fixation
of the implant. A common situation is implant placement
in the inter‑root septum, which causes the bone bed
surrounding the implant to condition very precarious
initial stability. This problem can be solved by using
an implant of larger diameter, waiting for the alveolar
space to fill with bone, and then performing delayed
placement or positioning two implants to reconstruct a
lower molar.[3,7,9,11,12]
161



Case clinic
Topics

History

Root resorption of two front teeth after orthodontics
therapy, extraction of front teeth, immediate placement
of implants at time of extraction, and immediate load
of implants with temporary crowns [Figures 1 and 2].

AN is an attractive 27‑year‑old that has been struggling
with the thought of losing her two front teeth. It is
not known why, but the roots of her two central have
resorbed. This has made the two front teeth very loose
for the past several years. AN has been concerned that

Figure 2: Implants in place with stock abutments
Figure 1: Retracted view pre op.

Figure 4: Miner Oss to fill in the facial
Figure 3: Abutments removed, Implants with flared
healing collars

Figure 5: Angled abutments placed 3 months post surgery
162

Figure 6: Implant placement, graft and membrane.
Flared healing collars



Figure 8: Post op smile
Figure 7: Final Zirconia coping crowns

these teeth will come out if she bites into something
hard or sticky. The teeth are not painful, but there is
grave concern about these teeth falling out; and once
they come out, how to replace them and make them look
beautiful. AN has high esthetic demands and is very
concerned that the replacement be immediate after the
extractions and be as good or improve her smile. AN
has a high smile line. Her upper teeth and gingiva are
not covered by her upper lip. Her teeth are in full view
when she smiles.

Treatment plan

A plan was developed with the patients prosthodontist,
to include extraction of the two upper central incisors,
# 8 and 9 [Figures 3‑5], immediate placement of two
implants into those extraction sites and immediate
temporary teeth on the implants to be fabricated by the
patients prosthodontist [Figure 6]. Once these implants
are osteointegrated, porcelain crowns will be fabricated.
Immediate ext/implantation with RePlant 5.0 × 13, Atlantis
abutments, and EMAX A2 crowns [Figures 7 and 8].

CONCLUSIONS
The present results indicate that immediate loading
of immediately placed dental implants replacing
single‑rooted teeth is a predictable treatment that
depends mainly on; good patient/case selection,
achieving good primary stability and maintaining
primary stability. Hence, from the present study we
conclude that the success of this technique depends on:
• Good patient and case selection
• Presence of sufficient healthy bone beyond the
periapical lesion
• Surgical technique used; atraumatic extraction, good
curettage of the extraction socket, and drilling at
least 3-4 mm beyond the root apex to gain maximum

degree of primary stability
• Implant selection; the implant has to be in length and
diameter greater than that of the extraction socket,
implants with a flared neck are better to be placed
into fresh extraction sockets to increase bone implant
contact at the coronal part of implant and implants
with rough surface are recommended to be used for
immediate loading
• Patients’ motivation and cooperation to follow
instructions and the follow‑up program.
Finally, it is important to note that the data of the present
study do not imply that delayed or delayed‑immediate
implant placement or submerged approaches are no
longer indicated.
Additional research can be performed to investigate
the possibility of immediate implant placement and
provisionalization in the anterior mandible and
in patients who are smokers, in old age, diabetics,
osteoporotics, or bruxers.

REFERENCES
1.

Ozdemir E, Lin WS, Erkut S. Management of interproximal soft
tissue with a resin‑bonded prosthesis after immediate implant
placement: A clinical report. J Prosthet Dent 2012;107:7‑10.
2. Viskić J, Milardović S, Katanec D, Vojvodić D, Mehulić K.
Immediate implantation in infected tooth sockets. Coll Antropol
2011;35:217‑21.
3. Di Felice R, D’Amario M, De Dominicis A, Garocchio S,
D’Arcangelo C, Giannoni M. Immediate placement of bone level
Sraumann implants: A case series. Int J Periodontics Restorative
Dent 2011;31:57‑65.
4. Alves CC, Neves M. Tapered implants: From indications to
advantages. Int J Periodontics Restorative Dent 2009;29:161‑7.
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restoration of single implants placed immediately after tooth
extraction. J Periodontol 2006;77:1914‑20.
6. Hoffmann O, Beaumont C, Zafiropoulos GG. Immediate implant
placement: A case series. J Oral Implantol 2006;32:182‑9.
7. Balshi TJ, Wolfinger GJ. Teeth in a day for the maxilla and
163


mandible: Case report. Clin Implant Dent Relat Res 2003;5:11‑6.
Romanos GE. Treatment of advanced periodontal destruction
with immediately loaded implants and simultaneous bone
augmentation: A case report. J Periodontol 2003;74:255‑61.
9. Liechtung M. A new approach to implant provisionalization.
Dent Today 2012;31:70,72,74, Hains FO. Immediate implant
placement in posterior areas: The mandibular arch. Compend
Contin Educ Dent 2012;33:494‑6,498,500.
10. Meltzer AM. Immediate implant placement and restoration in
8.

infected sites. Int J Periodontics Restorative Dent 2012;32:e169‑73.
11. Anitua E, Orive G. A new approach for atraumatic implant
explantation and immediate implant installation. Oral Surg Oral
Med Oral Pathol Oral Radiol 2012;113:e19‑25.
How to cite this article: Muhamad A, Azzaldeen A, Aspasia SA, Nikos
K. Implants into fresh extraction site: A literature review, case immediate
placement report. J Dent Implant 2013;3:160-4.
Source of Support: Nil, Conflict of Interest: None.

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Implants into fresh extraction site: A literature review, case immediate placement report

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