Immediate Implant Placement and Restoration

in the Esthetic Zone: A Prospective Study

with 18 Months of Follow-up
Pedro Tortamano, DDS, PhD1/Luiz Otávio Alves Camargo, DDS, PhD2/
Marina Stella Bello-Silva, DDS, PhD3/Lúcio Hirokuni Kanashiro, DDS, PhD4

Purpose: This clinical study aimed to assess the dimensional stability of peri-implant soft tissues around
immediately placed and restored implants in the maxillary esthetic zone. Materials and Methods: Twelve
systemically healthy patients presenting with a hopeless maxillary central incisor were selected. Provi-
sional restorations were delivered immediately after tooth extraction and implant placement. Peri-
implant soft tissue dimensions were measured either by direct clinical examination or evaluation of
study casts. Measurements were performed before extraction; immediately after implant and restoration
placement; and 6 weeks, 3 months, 6 months, 12 months, and 18 months postoperatively. The dis-
tances assessed were: tip of the mesial papilla to the mesioincisal edge of the adjacent central incisor,
tip of the distal papilla to the mesioincisal edge of the adjacent lateral incisor, and the length of the clini-
cal crown of the definitive restoration. Results: All patients completed the study, and no implants failed
within the 18-month follow-up period (100% survival rate). No statistical differences were observed in the
distances between the incisal edge of the adjacent teeth and the mesial and distal papilla tips (P = .303
and .099, respectively) at any follow-up appointment. Likewise, there were no alterations in the definitive
clinical crown dimensions during the follow-up period (P = .406). Conclusion: The findings of this
18-month prospective study indicate that, within the selection criteria and technique presented in this
study, immediate implants with immediate restorations can be a predictable option for the replacement
of teeth in the esthetic zone, providing stability to the peri-implant soft tissue. INT J ORAL MAXILLOFAC
IMPLANTS 2010;25:345–350

Key words: dental implants, immediate implants, immediate loading, soft tissue stability

he achievement of a favorable and predictable After extraction, a cascade of physiologic events

T prognosis after the reestablishment of function and
esthetics with dental implants has highlighted implant
treatment as one of the most important tools for oral
rehabilitation. However, a predictable esthetic result is
considered a challenge when an extracted tooth must
be replaced by an implant in the anterior maxilla.
1Associate Professor, Department of Prosthodontics, School of
Dentistry of the University of São Paulo, São Paulo, Brazil.
2Dean, School of Dentistry, Universidade Nove de Julho, São
Paulo, Brazil.
3Student, Department of Restorative Dentistry, School of Den-
tistry of the University of São Paulo, Brazil.
4Associate Professor, Postgraduation in Implantology, School of
Dentistry, Universidade Nove de Julho, São Paulo, Brazil.
Correspondence to: Dr Pedro Tortamano, Department of Prostho -
dontics, School of Dentistry of the University of São Paulo, Rua Jerôn-
imo da Veiga, 428, cj. 51, CEP: 04536 – 001 São Paulo – SP, Brazil.
Fax: +55-11-31688388. Email: tortamano@usp.br
takes place as the body seeks to repair the extraction
socket. These physiologic events can be detrimental
to the definitive esthetic results, since a significant
loss of both vertical and horizontal bone volume is
expected. 1,2 Immediate implant placement with
immediate provisional restoration of anterior
implants has been widely reported in the literature as
a possible solution for maintenance of soft and hard
tissue architecture.1–7 Some authors suggest that this
technique may negatively affect the remodeling
process of peri-implant tissue4; others suggest that
the space between the implant and the bone is filled
by clot, and this fact favors bone formation in this
area, resulting in an increased buccal bone thickness
and predictable esthetic outcomes.5 In contrast, some
studies have reported bone resorption even after
immediate placement and restoration of implants.8,9
This lack of peri-implant hard tissue stability is
thought to be detrimental for the maintenance of the
peri-implant soft tissue after temporization, leading
to unsatisfactory esthetic outcomes.

The International Journal of Oral & Maxillofacial Implants 345

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 Tortamano et al
Various advantages are associated with the imme-
diate placement and restoration of implants, such as
shorter treatment time, reduced number of surgical
interventions, and preservation of alveolar bone after
tooth extraction.10 On the other hand, disadvantages
such as difficulty in correctly positioning the implant,
presence of periapical pathology, thin tissue biotype,
lack of keratinized tissue, and hard tissue resorption
have also been reported.8,11 Because the literature is
not conclusive with regard to soft tissue stability
around immediately placed and restored implants,
the aim of this clinical prospective study was to
assess the stability of the peri-implant soft tissues in
the esthetic zone after an 18-month follow-up period.
MATERIALS AND METHODS
Twelve patients presenting with one maxillary central
incisor that had been deemed hopeless for reasons
other than periodontitis were selected. Patient selec-
tion meticulously followed the inclusion and exclu-
sion criteria presented in Table 1. To be included in
the present study, the patients needed to read and
sign the informed consent document, as specified by
the Ethical Committee for Human Studies of the Uni-
versity of São Paulo, Brazil, by which this study proto-
col was reviewed and approved.
Presurgical Procedures
After anamnesis and clinical examination, each
patient was examined radiographically and pho-
tographed (intraoral and extraoral), impressions were
made, basic periodontal procedures were performed,
and oral hygiene instruction was provided. A surgical
stent was produced that could be adapted on the
adjacent teeth and presented with anatomy identical
to that of the adjacent central incisor, as it would be
later used as a provisional restoration after implant
placement.
Tooth Extraction and Implant Placement
The hopeless incisor was carefully luxated with a perio -
tome and extracted with the help of mini-elevators
to prevent any lateral movement that might damage
both buccal and lingual bone plates. Residual peri-
odontal tissue and any remaining debris were
removed from the extraction sockets with the use of a
curette. A periodontal probe was used to scan the
internal surface of the alveolus for dehiscences and
fenestrations before implant placement. If any bone
defects were detected, the technique was no longer
indicated and the patient was immediately excluded
from the study, because delayed implant placement
would be preferable. Likewise, patients could not
346 Volume 25, Number 2, 2010
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present with a distance of more than 4 mm between
the bone crest and the buccal and palatal mucosal
margins12 or a distance of more than 5 mm between
the bone crest and the interproximal mucosal mar-
gins.13,14
Since a flap was not raised during extraction, the
mucosal margin was used as a reference for drilling
depth. The surgical stent was positioned and the drill
was inserted to a depth of 16 mm from the mucosal
margin, as it included 12 mm of implant length and
approximately 2 mm of the distance to the bone
crest.
The absence of fenestrations and dehiscences was
verified again after the osteotomy was completed. A
tapered-effect implant (Straumann Dental Implant
System, Institut Straumann) with a sandblasted and
acid-etched rough surface was placed into a correct
three-dimensional position, according to Buser and
Wismeier15: mesiodistally, the implant should be at
least 1.5 mm away from neighboring teeth; buccolin-
gually, it should be positioned 1 to 2 mm from the
ideal emergence point of the future prosthesis; apico-
coronally, the implant shoulder should be positioned
2 mm apical to the mucosal margin; and the treated
implant surface was always fully submerged in bone.
The implant dimensions were: 1.8 mm of a smooth
neck, 4.1-mm apical diameter, 4.8-mm cervical diame-
ter, and 12-mm length. The tapered-effect implants
reduced the extent of any peri-implant gaps (gaps
between implant and bone plate) to less than 2 mm,
and no filling material or membrane was used.
Immediate Provisional Restoration
The achievement of primary implant stability enabled
the immediate delivery of a screw-retained provi-
sional crown. This provisional restoration was cus-
tomized by adapting the surgical stent to a
prefabricated titanium post with acrylic resin. Special
attention was given to the production of optimal
marginal fit and adequate contour, as the restoration
needed to fill the space once occupied by the tooth
and support the surrounding soft tissue without
exerting any pressure on it. The restoration was
designed to be completely in contact with the sur-
rounding mucosa, so that any exposure of peri-
implant gaps was avoided and no sutures were
required for wound closure.
The provisional restoration was kept out of
occlusal contact in both centric and excursive jaw
movements. Patients were instructed to avoid masti-
cation in the treated area for at least 6 weeks. Periapi-
cal radiographs and alginate impressions were
obtained immediately after temporization.

Table 1 Established Inclusion and Exclusion Criteria for the Study
Inclusion criteria
One maxillary central incisor deemed hopeless for a reason other than
periodontitis
Absence of medical conditions contraindicating surgical intervention
Sufficient alveolar bone architecture to allow primary implant stability
Mucosal margin distant 4 mm to buccal/palatal bone crest and 5 mm to
interproximal bone crest
Attendance at all follow-up appointments
Written informed consent
Table 2 Clinical Measurements at Each Follow-up Examination
Measurement Baseline 6 wk 3 mo
CI 6.34 ± 1.17 6.35 ± 1.21 6.24 ± 1.31
LI 6.13 ± 1.03 6.24 ± 1.80 6.24 ± 1.02
DR – 10.00 ± 1.12 9.96 ± 1.17
Mean values ± standard deviations shown. CI = tip of the mesial papilla to the mesioincisal edge of the adjacent central incisor; LI = tip of the distal
papilla to the mesioincisal edge of the adjacent lateral incisor; DR = length of the clinical crown of the definitive restoration.
Definitive Restoration
At 6 weeks postoperatively, the definitive screw-
retained metal-ceramic crown was delivered. 16,17
Impression posts were customized to transfer the soft
tissue architecture to the working cast and enable
the dental technician to fabricate a definitive pros-
thesis with an emergence profile identical to that of
the provisional crown.
Data Gathering and Statistical Analysis
The clinical dimensions of the poured casts were
assessed with the aid of a digital pachymeter (Von-
der). Dimensions of the peri-implant soft tissue were
measured on the casts before extraction (baseline),
immediately after provisional restoration delivery,
after 6 weeks (definitive restoration delivery), and 3, 6,
12, and 18 months postoperatively. The following
dimensions were measured in millimeters: (1) tip of
the mesial papilla to the mesioincisal edge of the
adjacent mesial tooth, (2) tip of the distal papilla to
the mesioincisal edge of the adjacent distal tooth,
and (3) length of the clinical crown of the definitive
restoration. Three different researchers performed
three consecutive measurements of each dimension.
Mean values and standard deviations were calculated
for each dimension (Table 2). The test for normality
indicated that the values were not normally distrib-
uted. Therefore, the Friedman test was used to calcu-
late the statistical significance of any changes. The
significance level was set at 5%.
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Tortamano et al
Exclusion criteria
Acute infection in the condemned tooth
Active periodontal disease in any region of the mouth
Interproximal bone loss in the area to receive an implant
Active smoking status
Fenestrations and dehiscence of the alveolar wall after tooth
extraction
Inadequate primary stability of the implant
6 mo 12 mo 18 mo
6.21 ± 1.27 6.19 ± 1.20 6.20 ± 1.20
6.21 ± 1.08 6.13 ± 1.02 6.10 ± 0.99
10.01 ± 1.24 9.94 ± 1.23 9.97 ± 1.26
RESULTS
Twelve patients (three men and nine women) present-
ing with a total of 12 hopeless incisors in the maxilla
fulfilled the inclusion criteria and were enrolled. All
patients finished the study and were followed from
baseline to the final 18-month follow-up examination.
The patients’ ages ranged from 22 to 54 years, and all
of them showed good general health. Primary implant
stability was achieved in all patients, and no postsurgi-
cal complications were observed. All implants were
osseointegrated at 6 weeks postoperatively, and no
implants were lost during the 18-month follow-up
period, yielding an 18-month survival rate of 100%.
Seven implants were placed in the left central
incisor position (58.33%) and five were placed in the
right central incisor position (41.67%). The initial diag-
noses indicated that two teeth were condemned
because of root resorption (16.67%), seven because
of root fracture (58.33%), two because of endodontic
treatment failure (16.67%), and one as a result of
root caries (8.33%). Eight patients (66.67%) presented
satisfactory soft tissue architecture at baseline,
whereas four patients required corrections on the
contours of the provisional restoration to achieve
more harmonious esthetics.
The measurements of the designated dimensions at
each follow-up appointment are presented in Table 2.
The Friedman test indicated no statistically significant
differences in the variations of dimension between
The International Journal of Oral & Maxillofacial Implants 347
 Tortamano et al

6.7 6.6
6.6 6.5
6.5 6.4
6.4 6.3

LI (mm)
CI (mm)

6.3
6.2
6.2
6.1
6.1
6.0 6.0
5.9 5.9
5.8 5.8
0 6 12 24 48 72 0 6 12 24 48 72
Time (wk) Time (wk)

Fig 1 Means and standard deviations of the distance between Fig 2 Means and standard deviations of the distance between
the tip of the mesial papilla and the mesioincisal edge of the the tip of the distal papilla and the mesioincisal edge of the adja-
adjacent central incisor (CI) at each follow-up session. cent lateral incisor (LI) at each follow-up session.

10.4
10.3
10.2
10.1
DR (mm)

10.0
9.9
9.8
9.7
9.6
9.5
0 6 12 24 48 72
Time (wk)

Fig 3 Means and standard deviations of the length of the clinical

crown of the definitive restoration (DR) at each follow-up session.

the tip of the mesial papilla and the mesioincisal
edge of the adjacent central incisor (P = .303) or
between the tip of the distal papilla and the mesioin-
cisal edge of the adjacent lateral incisor (P = .099).
Likewise, no statistically significant alterations were
observed in the length of the definitive restorations
during the 18-month follow-up period (P = .406).
The distance between the tip of the mesial papilla
and the mesioincisal edge of the adjacent central
incisor seemed to have stabilized by the 6-month fol-
low-up appointment (Fig 1). A steady decline was
observed in the distance between the tip of the distal
papilla and the mesioincisal edge of the adjacent lat-
eral incisor after 6 weeks and 3 months postopera-
tively (Fig 2), but these changes were not statistically
significant. The definitive restoration length remained
stable during the entire follow-up period (Fig 3).
The results of the statistical analysis corroborated
the clinical outcomes observed, since the dimensions
of the peri-implant soft tissue were stable and the
esthetic contours obtained soon after treatment were
maintained. The follow-up examinations revealed sta-
ble soft tissue levels and contours for up to 18 months.
DISCUSSION
The placement of implants in fresh extraction sockets
has been discussed increasingly frequently in the lit-
erature and performed by clinicians in daily practice,
since the maintenance of bone architecture that
results from this technique seems to significantly
help esthetic outcomes, especially with regard to the
anterior maxilla or “esthetic zone.”4,6,18–21 It has been
suggested that immediate temporization may be an
important alternative to covering an immediate
implant, as it may solve the problem of lack of soft tis-
sue for flap closing.4,20

348 Volume 25, Number 2, 2010

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Despite the various advantages reported in the lit-
erature, the disadvantages related to the lack of sta-
bility of surrounding peri-implant tissues after
immediate placement and restoration of implants
have kept this technique controversial.22–24 Therefore,
the present study aimed to evaluate the stability of
soft tissue around immediately placed and restored
implants. To ensure that the technique was per-
formed meticulously, the protocols reported by
Wöhrle4 and Kan et al25 were followed strictly.
The results observed in the present study indicate
that the peri-implant soft tissues around immediately
placed and restored implants are stable and may
ensure a predictable outcome for this technique in
the anterior maxilla. There were no statistically signifi-
cant differences in any of the measurements per-
formed at each follow-up examination. With regard to
crown length, the measurements were initiated after
the delivery of the definitive prosthesis. It was not
possible to compare the crown anatomy before and
after tooth extraction, since in four patients the
crowns had to be revised for esthetic reasons at the
time of provisional restoration. It is important to
emphasize that the esthetic success and the favor-
able outcomes are attributed to the correct execution
of the surgical and prosthetic techniques, as well as to
the inclusion criteria previously established.
Certain details regarding the surgical technique
must be precisely followed and are paramount in
achieving favorable results. Accurate analysis of tooth
alveolus integrity where the implant is subsequently
placed is an example. This integrity is related to the
maintenance of bone structure during peri-implant tis-
sue healing and, consequently, to soft tissue stability.
Because a flapless approach was taken, it was not pos-
sible to measure the thickness of the buccal bone
before implant placement. Therefore, buccal bone
measurement was limited to its height, integrity, and
position. Although buccal bone thickness was not
measured, it seemed not to have influenced the out-
comes during the study period. Precise placement of
the implant also plays an important part in soft tissue
stability, and with regard to immediate implant place-
ment and flapless surgery, the distance between the
bone crest and the mucosal margin must not exceed 4
mm in the buccal/palatal area12 and 5 mm in the inter-
proximal area.14,26 When these values are respected, it
is ensured that the distance between the implant
shoulder and the mucosa margin will not exceed 2
mm, preventing deeper placement of the implant and,
therefore, recession of the adjacent soft tissue. The dis-
tance between the implant and the roots of adjacent
teeth must be at least 1.5 to 3 mm.27 These dimensions
aim to prevent excess remodeling of the supporting
bone and the associated soft tissue collapse/recession.
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Tortamano et al
Immediate temporization was performed and
screw retention was preferred to prevent the possible
leakage of cement between the implants and the
peri-implant tissues, which may have compromised
their integration. The emergence profile of the provi-
sional crown should be customized to support the
peri-implant surrounding tissues, and this contour
should be reproduced by the dental technician when
fabricating the definitive restoration.4,25
Other factors related to the achievement of tissue
stability are thought to be the correct indication of
the technique during planning stage, the mainte-
nance of soft tissue contours during prosthetic proce-
dures, and the absence of raising a flap. The latter is
considered an important advantage of this technique,
since previous studies have demonstrated that raising
a mucoperiosteal flap disrupts the local blood supply
and causes a certain degree of bone resorption.28–32
The main motivation for this study was the pres-
ence of significant controversies in the literature
regarding the stability of peri-implant soft tissue. The
esthetic stability of soft tissues obtained by Wöhrle4
was contradicted by the results of Araújo et al,8 who
showed that immediate implants were not able to
prevent resorption of the buccal bone plate in dogs.
Buccal plate resorption and consequent fenestration
of the implant would have significant implications in
soft tissue and esthetics, such as recession and
thread/platform exposure, which may result in per-
ceived gingival discoloration. The present study
aimed to evaluate the alterations in the peri-implant
soft tissues from the time prior to tooth extraction
and implant placement to 18 months after definitive
prosthetic rehabilitation, according to the techniques
proposed by Wöhrle4 and Kan and Rungcharassaeng5
and described by Tortamano et al.33
The authors attribute the positive results of the pre-
sent study mainly to the strict selection criteria and
indication of the technique, as well as to the precise
execution of the method described. The clinical and
statistical analyses indicate that the alterations in papil-
lae height and crown length were negligible, attesting
to the esthetic and dimensional stability of the peri-
implant soft tissues after 18 months of follow-up.
CONCLUSIONS
The findings of this 18-month prospective study indi-
cate that, within the selection criteria and technique
presented in this study, immediate implants with
immediate restorations can be a predictable option
for the replacement of teeth in the esthetic zone, pro-
viding stability to the peri-implant soft tissues.
The International Journal of Oral & Maxillofacial Implants 349
 Tortamano et al
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