A Step-by-Step Approach for Selecting Immediate Implant Placement or Socket Preservation

1. A Step-by-Step Approach
for Selecting Immediate
Implant Placement or
Socket Preservation
Robert Carvalho da Silva, DDS, MS, PhD
Paulo Fernando Mesquita de Carvalho, DDS
Júlio César Joly, DDS, MS

2. Dr. Da Silva practices and is a clinical director at ImplantePerio Institute in
São Paulo, Brazil. He can be contacted at robert@implanteperio.com.br
Dr. Carvalho practices and is a clinical director at ImplantePerio Institute in
São Paulo. He can be contacted at paulofernando@implanteperio.com.br
Dr. Joly practices and is a clinical director at ImplantePerio Institute in São
Paulo. He can be contacted at joly@implanteperio.com.br
Disclosures: The authors did not report any disclosures.

3. All images in this slideshow are copyright protected and belong to the authors.
Copyright © 2016. All rights reserved. No part of this slideshare may be reproduced,
distributed, or transmitted in any form or by any means, including copying, recording, or other
electronic or mechanical methods, without the prior written permission of the publisher.

4. Fresh socket management requires a critical evaluation of biological and esthetic risk
factors (residual bone, gingival margin position, buccal bone characteristics, tissue biotype,
and infection) to pave the way for the most appropriate decision-making process.
This slideshow offers guidelines to help the clinician select either socket preservation or
immediate implant placement after minimally invasive flapless tooth extraction. The
hypothesis is that the timing of implant placement should not interfere with the final
clinical outcome as long as these three pillars of success are observed:
1. adequate three-dimensional implant positioning,
2. esthetic tissue reconstruction,
3. and prosthetic management.

5. Socket
reconstruc,on
using
anorganic
bone
mineral,
collagen
membrane,
and
rotated
pedicle
connec,ve
,ssue
gra7.
Clinical
aspect
of
the
upper
le7
canine,
with
deep
gingival
recession,
lateral
frenulum,
and
loss
of
the
mesial
papilla.
Slides 4 through 9 illustrates a socket preservation clinical case.

6. CBCT of the affected tooth,
showing ankylosis and
root resorption.
Flapless tooth extraction.

7. The collagen membrane in position, after an
envelope-like mucoperiosteal flap was raised.
The socket was filled and packed with
biomaterial.

8. The pedicle connective tissue graft was rotated from the palatal area to seal the
socket and secured with sutures.

9. Clinical image after six months, showing
satisfactory tissue volume and that the
frenulum had been removed.
Flapless implant placement after a circular
punch incision.

10. Occlusal and buccal views one year after final prosthesis delivery.
Note the nice leveling of the gingival margins at the anterior
region and interproximal papillary.
CBCT one year after
final prosthesis
delivery.

11. Immediate implant placement in a compromised socket (no buccal wall). Buccal and occlusal views of
the right upper central incisor showing an apical lesion, but with thick tissue biotype and leveled
gingival margin position.
Slides 10 through 19 show a case in which an immediate implant
placement was performed despite the socket being compromised.

12. CBCT of the affected
tooth depicting no
buccal wall.
Removed tooth with
deep root resorption
and apical lesion.

13. After minimally traumatic tooth extraction,
the probe confirmed the complete absence
of the buccal bone wall.
Envelope-like mucoperiosteal flap prepared
using tunneling instrumentation.

14. Immediate implant placement. Occlusal view of the implant in position,
highlighting the importance of using
narrow-platform implants, and positioned
according to prosthetic requirements.

15. Customized provisional titanium abutment-
screw retained to implant.
The implant-supported provisional
restoration is prepared and finished
before the esthetic tissue reconstruction
phase.

16. Occlusal view of the collagen membrane below the flap
to protect the bone graft that will be used to fill the gap.

17. Blades of anorganic bovine bone-derived mineral embedded in 10% of collagen
were used to fill the gap.

18. Buccal and occlusal views of the screw-retained provisional restoration in position.

19. Occlusal view six months later, immediately
after the provisional restoration was
removed, showing the excellent volume and
architecture of the soft tissue.
Custom esthetic abutment positioned
adjacent to the prepared right central
incisor.

20. Buccal and lateral views of the metal-free crowns in position
one year after cementation, showing natural-looking
appearance and perfect symmetry.
Final CBCT obtained at one-
year follow-up, showing
complete reconstitution of
the buccal bone supporting
the soft tissue.

21. Socket preservation followed by late or immediate implant placement, are both effective
methods for restoring anterior hopeless teeth. Proper diagnosis is essential in achieving
predictable long-term esthetic outcomes.
The step-by-step approach discussed in this slideshow is helpful when it comes to
treatment planning these types of cases. Following the three pillars of success these two
methods should lead to similar successful outcomes.

22. _________________________________
The AACD would like to thank the authors of
this slideshow for their work and dedication
to the education in esthetic dentistry.
_________________________________

23. This slideshow was an excerpt from the original article published in the Journal of Cosmetic
Dentistry, Summer 2015, Volume 31, Number 2, titled: Socket Management in the Esthetic Zone
authored by Robert Carvalho da Silva, DDS, MS, PhD, Paulo Fernando Mesquita de Carvalho,
DDS, and Júlio César Joly, DDS, MS.
To receive the quarterly, peer-reviewed Journal of Cosmetic Dentistry,
available to members only, enroll as an AACD member at www.aacd.com/join