DOI: 10.1111/prd.
12252
REVIEW ARTICLE
Socket healing with and without immediate implant
placement
Mauricio G. Araújo1 | Cleverson O. Silva1 | Andrė B. Souza2 | Flavia Sukekava3
1
Department of Dentistry, State University of Maringá, Maringá, Parana, Brazil
2
Department of Prosthodontics, Tufts University School of Dental Medicine, Boston, Massachusetts
3
Private practice, Curitiba, Parana, Brazil
Correspondence
Mauricio G. Araújo, Department of Dentistry, State University of Maringá, Maringá, Parana, Brazil.
Email: odomar@hotmail.com
KEYWORDS
alveolar ridge, extraction socket, immediate implant, Latin America
1 | INTRODUCTION
Several clinical and experimental studies reported that the replace-
ment of a hopeless tooth by an implant installed in a fresh extraction
socket (immediate implant, Figure 1) is a predictable procedure (for
review, see Lang et al1). Such studies demonstrated survival rates
similar to the historical data observed in late implant placement
(more than 6 months following tooth extraction). In addition, it has
been suggested that an immediate implant placement may prevent
post‐extraction bone loss and, hence, improve the esthetic outcome
2
of the final rehabilitation.
The implant placement in a fresh extraction socket is a complex
procedure that involves many important aspects. In fact, for a success-
ful clinical outcome, immediate implant installation should take into
consideration several aspects such as socket healing process, implant
characteristics, alveolar process anatomical features such as buccal
bone width, gap between the implant surface and the inner portion of
F I G U R E 1 Clinical photography illustrating an implant installed in
a fresh extraction socket (immediate implant)
168 | © 2019 John Wiley & Sons A/S. wileyonlinelibrary.com/journal/prd
Published by John Wiley & Sons Ltd
the socket walls, the need for regenerative procedures, and improved
surgical techniques. All these aspects were addressed by several
clinical and experimental studies performed in Latin America. Thus,
the aim of the present review was to describe the studies produced
in Latin America that contributed to the elucidation of the effect of
tooth extraction with and without immediate implant installation.
An eletronic search including clinical and experimental (animal)
studies involving or not immediate implant placement was conducted
at MEDLINE (Pubmed), Scopus, Lilacs and Embase databases. The
studies selected had to fulfill the following inclusion criteria: (i) to
present clinical and/or histological data on socket healing with or
without immediate implant installation; (ii) to be approved by a Latin
American Ethic Committee or comparable; and (iii) to include at least
one author from a Latin American institution or to be conducted in a
Latin America institution.
The studies that fulfilled the inclusion criteria are described in
Tables 1 and 2. The studies included were mainly performed in Brazil
but also other Latin American countries such as Chile, Argentina,
Mexico and Cuba provided important contributions. The research
models applied were predominantly animal models and, in compar-
ison, fewer clinical studies were produced. Most of the animal stud-
ies were performed using the dog model while the rat, monkey, and
mini pig models were utilized in some studies. The variables analyzed
in the studies included amount of tissue formation and loss, amount
of dimensional alteration, and various clinical and radiographic
parameters. The current review is divided into two parts: socket
healing and socket healing with immediate implant placement.
2 | SOCKET HEALING
The first Latin American study on socket healing was performed in
Argentina at the University of Buenos Aires by Guglielmotti and
Periodontology 2000. 2019;79:168–177.
T A B L E 1 Characteristics of included studies in humans
Number of Outcome
ARAÚJO

Study Design Procedure Teeth teeth measurements Time of healing Follow‐up Country Notes
3
ET AL.

Anchieta et al Case report Immediate implant installed Maxillary left central 1 Improvement of Not informed Not informed Brazil Faculty of Dentistry
and provisional prosthesis incisor esthetics of Araçatuba, São
Paulo State
University‐UNESP
Barcelos et al4 Case report Immediate implant installed Maxillary right 1 Clinical outcomes 3 mo Not informed Brazil Unigranrio
in fresh extraction socket, central incisor University
and provisional crown
delivered
Bersani et al5 Case series Immediate implant installed Molars 23 Clinical and radiographic Minimum of Minimum of 4 Brazil Private practice,
in mandibular molar region, evaluation 4 mo and maximum Ribeirão Preto
flapless and graftless, of 85 mo
provisional crown installed
Hernández Case report Immediate implant Maxillary incisors 3 Clinical and radiographic 5 mo Not informed Mexico School of Dentistry
and López16 instalation and GBR evaluation of UNAM
Jofre et al6 Case series Immediate implant Nonmolars At least 31 Incidence of post‐ At least 6 mo Not informed Chile University of
instalation and provisional surgical complications Concepcion
in infected sockets and clinical variables
Naves et al7 Case report Immediate implant installed Maxillary incisors 3 Clinical and radiographic 6 mo 3y Brazil HD Postgraduate
in fresh extraction socket, evaluation Dental Education
associated with GBR Center, Uberlândia
Novaes and Case report Immediate implant installed Mandibular premolar 1 Clinical and radiographic 6 mo 1y Brazil Private practice
Novaes8 in fresh extraction socket, evaluation
associated with GBR
Novaes et al9 Case report Tooth extraction, immediate Maxillary left first 1 Clinical and radiographic 6 mo Not informed Brazil School of Dentistry,
implant installation, graft premolar evaluation University of São
with bio glass and covered Paulo‐ Ribeirão
by adermal cellular matrix Preto
as a barrier
Oliveira et al10 Case report Teeth extraction and Mandibular molars 2 Clinical and radiographic Not informed 1y Brazil School of Dentistry,
immediate implant evaluation University of São
placement Paulo‐ Ribeirão
Preto
Ribeiro et al11 Case series Immediate implant and Maxillary nonmolars 46 Clinical and radiographic 6 mo 2y Brazil Private practice and
provisional prosthesis evaluation University of São
Paulo‐Araraquara
Saldanha et al14 Prospective Maxillary tooth extraction Nonmolar 21 Clinical and radiographic After 6 mo, 6 mo Brazil School of Dentistry,
comparison between smokers showed University of
smokers and lower levels of Campinas‐
nonsmokers socket bone density Piracicaba
|

healing

(Continues)
169
170 | ARAÚJO ET AL.

Cabrini.26 The authors evaluated in a rat model the socket healing

School of Dentistry,
University of São
after tooth extraction at different time intervals. It was found that

Paulo, São Paulo

Private practice

Private practice
post‐extraction bone resorption reached its peak at the seven‐day
time interval and bone formation peaked after 14 days of healing.
This study was followed by many other clinical and experimental

Notes
studies performed in Latin America that provided fundamental con-
tributions to implant dentistry.
Country

Mexico

Mexico
In 2003, Cardaropoli et al24 initiated a series of animal studies
Brazil

that evaluated the socket healing process in detail. The studies

described the dynamics of socket healing and the dimensional alter-
ations following tooth extraction. The first study of the series
Follow‐up

described in the dog model the dynamics of bone tissue formation in

18 mo

tooth extraction sites after different time intervals, namely one,

1y

three, seven, 14, 30, 60, 90, 120, and 180 day(s).24 Biopsies were
obtained from the sockets representing the different time intervals
Time of healing

and histological sections cut in the mesio‐distal plane were prepared

for histological analysis. Morphometric measurements were per-
6 mo

6 mo
6 wk

formed to determine the volume occupied by different types of tis-

sues in the extraction socket. The results demonstrated that
immediately following tooth extraction the socket was filled with a
Clinical and radiographic

Clinical and radiographic

Clinical and radiographic

blood clot. Later, an infiltrate of inflammatory cells migrated to the

wound and formed a granulation tissue. At the two‐week time inter-
measurements

val, most of the blood clot and granulation tissue were replaced by a
evaluation

evaluation

evaluation
Outcome

provisional connective tissue (provisional matrix). Two weeks later,

this provisional matrix was mainly replaced by woven bone, a fast‐
forming bone with no load‐bearing capacity. During the following
weeks of healing, the woven bone was gradually removed by the
Number of

action of osteoclasts and replaced by bone marrow and lamellar

teeth

bone.
12

16
8

In summary, socket healing is a well‐orchestrated process that

can be divided into three overlapping phases, inflammatory, prolifer-
Maxillary non molar
Maxillary central

Maxillary molars

ative, and modeling and remodeling. During the inflammatory phase,

blood clot and granulation tissue are formed while, in the prolifera-
tive phase, new immature tissue is formed (provisional matrix and
incisor
Teeth

woven bone). In the third and final phase, modeling and remodeling,
the immature tissue is removed and replaced by mature and orga-
nized new tissue (bone marrow and lamellar bone).
Later on, Araújo and Lindhe17 evaluated the dimensional alter-
Immediate implant and

Immediate implant and

provisional prosthesis

provisional prosthesis

ations of the alveolar ridge that occurred following tooth extraction,

Immediate implant

as well as the processes of bone modeling and remodeling associated

with such change. The study included dogs that had their distal roots
installation
Procedure

of the third and fourth mandibular premolars extracted. Biopsies from

the healing sockets were obtained and represented one, two, four,
and eight weeks of healing. The tissue blocks were decalcified in
Case report

Case report
Prospective

EDTA, embedded in paraffin and cut in the buccal‐lingual plane. The

GBR, guided bone regeneration.

authors observed that there was marked bone modeling activity (sur-
Design
(Continued)

face osteoclastic activity) resulting in resorption of the crestal region

of both buccal and lingual bone walls. The reduction of the height of
12

the walls was more pronounced at the buccal than at the lingual
Tortamano et al

aspect of the extraction socket. Thus, during socket healing the pro-
Vergara and

Vergara and
Cafesse13

Cafesse15
TABLE 1

cess of bone modeling that took place resulted in dimensional reduc-

Study

tion of the alveolar ridge. The authors also demonstrated that the
resorption of the socket walls occurred by two concomitant phases:
ARAÚJO ET AL. | 171

T A B L E 2 Characteristics of included studies in animals

Study Animal model Procedure Parameter Time healing Outcome Country
Araújo et al32 Beagle dog Immediate implant with Histologic ‐ socket 6 mo Xenograft Brazil
and without xenograft dimensional compensate
alterations marginal ridge
contraction
Araújo and Lindhe17 Mongrel dog Tooth extraction Histologic ‐ socket 1, 2, 4, Buccal wall reduction Brazil
and healing dimensional and 8 wk
alterations
Araújo and Lindhe18 Beagle dog Socket healing with and Histologic ‐ socket 6 mo No difference Brazil
without flap elevation dimensional between groups
alterations
Araújo et al33 Beagle dog Tooth extraction vs Histologic ‐ socket 3 mo Implant does Brazil
immediate implant dimensional not prevent ridge
placement alterations remodeling
Araújo et al34 Beagle dog Immediate implant Histologic ‐ socket Immediate, 1 Initial bone‐to‐ Brazil
placement and healing dimensional and 3 mo implant contact is
alterations lost
Araújo et al35 Beagle dog Immediate implant Histologic ‐ socket 1 and 3 mo Buccal and lingual Brazil
placement and healing dimensional wall resorption
alterations
Caneva et al19 Labrador dog DBBM particles Histologic ‐ socket 4 mo Contributed to the Brazil
concomitantly with the dimensional preservation of the
application of a collagen alterations alveolar process
membrane used at
immediate implants
Caneva et al36 Labrador dog Immediate implants Histologic ‐ socket 4 mo DBBM + membrane Brazil
with and without dimensional improve
deproteinized alterations regeneration but
bovine bone mineral + present limited
collagen membrane effect on buccal
wall preservation
Caneva et al20 Labrador dog Immediate implants: 3.3 Histologic ‐ socket 4 mo Buccal and lingual Brazil
cylindrical × 5.0 conical dimensional and resorption is higher
soft tissue and mucosa is
alterations localized apically in
5.0 conical
Caneva et al37 Labrador dog Immediate implant Histologic ‐ socket 4 mo Membrane partially Brazil
with and without dimensional prevent buccal
collagen membrane alterations outline
Caneva et al21 Labrador dog Immediate implant Histologic ‐ socket 4 mo No difference Brazil
with and without flap dimensional between groups
elevation alterations
Caneva et al22 Labrador dog Immediate implants: Histologic ‐ socket 4 mo Resorption in both Brazil
alveolar central position dimensional groups / less
X lingual and deep alterations exposition of rough
position surface in deep and
lingual implants
Caneva et al38 Labrador dog Immediate implants: 3.3 Histologic ‐ socket 4 mo Buccal and lingual Brazil
cylindrical × 5.0 conical dimensional resorption is higher
alterations in 5.0 conical
Cardaropoli et al23 Mongrel dog Tooth extraction healing Histologic ‐ socket 3 mo No difference Brazil
with and without PDL dimensional between groups
alterations
Cardaropoli et al24 Mongrel dog Tooth extraction Histologic ‐ socket 1, 3, 7, 14, 3 healing phases Brazil
and healing healing process 30, 60, 90,
120, 180 d

(Continues)
172 | ARAÚJO ET AL.

TABLE 2 (Continued)
Study Animal model Procedure Parameter Time healing Outcome Country
Coelho et al39 Mongrel dog Immediate implants Histologic ‐ socket 4 wk No difference Brazil
with and without dimensional between groups
surface treatment alterations
Coelho et al25 Mongrel dog Immediate implants Histologic ‐ socket 4 wk Textured surface Brazil
with and without dimensional implants present
surface treatment in alterations less bone loss at
the collar area buccal cervical
region
Favero et al40 Labrador dog Immediate implants Histologic ‐ socket 3 mo Absence of adjacent Cuba and Brazil
with and without dimensional teeth increases
adjacent teeth alterations bone resorption
Guglielmotti Rats Tooth extraction Histologic ‐ socket Bone volume and Argentina
and Cabrini26 healing process and density increases at
dimensional the apical third /
alteration / greatest resorption
radiographic bone at 7 d and
density maximum bone
formation at 14 d
Marcaccini et al27 Mongrel dog Immediate implants into Histologic ‐ socket 12 wk No difference Brazil
infected or noninfected healing process between groups
sites (periodontal
disease)
Novaes et al28 Mongrel dog Immediate implants into Histologic ‐ bone‐to‐ 12 wk No difference Brazil
infected or noninfected implant contact between groups
sites (periodontal
disease)
Novaes et al29 Mongrel dog Immediate implants into Histologic ‐ bone‐to‐ 12 wk No difference Brazil
infected sites implant contact between groups
(periodontal disease)
with different surfaces
treatment: grit‐blasted /
acid‐etched X titanium
plasma spray
Novaes et al30 Dogs Immediate implant into Histologic ‐ bone‐to‐ 12 wk No difference Brazil
infected or noninfected implant contact between groups
sites (periapical lesions)
Papalexiou et al31 Mongrel dog Immediate implants in Histologic ‐ socket 12 wk No difference Brazil
periodontal disease area bone formation between groups
with different surface
treatment: grit‐blasted/
acid‐etched and
titanium plasma spray

DBBM, deproteinized bovine bone mineral; PDL, periodontal ligament.

phase 1, resorption of the bundle bone (inner portion of the socket);
and phase 2, resorption of the outer surface of the socket walls.
These two phases promoted considerable vertical reduction of the
buccal wall (Figure 2). These histological findings were strongly sup-
ported by various clinical studies from outside Latin America.41–44 The
reasons for the dimensional reduction of the alveolar ridge remains
undetermined but it may be related to the loss of the periodontal liga-
ment, functional adaptation, and genetics factors.
Further studies performed in Latin America have also investi-
gated if different surgical protocols for the tooth extraction proce-
dure could influence the socket healing process. One of these
surgical protocols was addressed by Cardaropoli et al,23 who
assessed the role of the periodontal ligament during socket healing.
In the dog model, the authors extracted roots on both sides of the
mandible. On one side of the mandible, the periodontal ligament
was scraped away from the socket walls after the extraction, while
in the contralateral socket, the periodontal ligament was left intact.
Three months later, histological analysis of the experimental areas
was carried out, and it was found that the socket healing was simi-
lar between the two experimental sites. Thus, it was demonstrated
that the periodontal ligament following tooth extraction does not
significantly interfere with the socket healing process.
Another aspect of the surgical protocol for tooth extraction
examined by a Latin American study was the effect of a full
ARAÚJO ET AL. | 173

F I G U R E 2 Microphotograph of a buccal‐lingual section

representing a healed extraction socket. Note that the marginal
portion of the buccal wall is markedly resorbed. The arrows indicate
bone crest: B, buccal bone wall; BM, bone marrow; L, lingual bone
wall. Ladewig fibrin stain, original magnification × 160

thickness flap elevation on the dimensional alteration of the alveolar

ridge.18 The authors observed that after six months of healing similar
amounts of bone loss occurred irrespective if the procedure used to
remove the tooth was flapless or included flap elevation. These find-
ings were supported by other experiments which evaluated flapless
tooth extraction.21,45 The results demonstrated that a flapless
approach had a certain benefit on the early stages of the healing
process but failed to prevent, over long‐term follow‐ups, bone
F I G U R E 3 Clinical photography of a maxillary premolar site
modeling following tooth extraction.
before and after extraction. Note the profile of the buccal aspect of
The ridge alterations following tooth removal were also studied the ridge (A) before tooth extraction and (B) four months later. Note
in smokers by Saldanha et al.14 The authors compared in a prospec- also the substantial reduction in the buccal‐lingual dimension of the
tive study the socket healing process between smokers and non- healed ridge
smokers using radiographic assessments. The study included only
anterior maxillary teeth extracted from 21 healthy adult patients. aspects of the sockets may lead to esthetic problems because of loss
The authors observed that smokers presented significantly more of tissue volume (Figure 3).
reduction in alveolar ridge width and radiographic bone density than
nonsmokers. It was suggested that smoking may affect the bone
modeling/remodeling process after tooth extraction leading not only 3 | SOCKET HEALING WITH IMMEDIATE
to a more significant dimensional reduction of the residual alveolar IMPLANT PLACEMENT
ridge, but also to a delayed socket healing.
In summary, tooth extraction promotes dimensional alterations It has been proposed that the immediate placement of implants fol-
that will result in the reduction of the alveolar ridge volume. Further- lowing tooth extraction could prevent or decrease dimensional
more, at extraction sites with thin buccal bone walls (< 1 mm), it is reduction of the alveolar ridge.7,9,15,16 Indeed, several authors in
frequently observed that the bone wall will be markedly reduced. It Latin America suggested the immediate implant placement as an
is important to note that at the anterior region of the maxilla, the approach to improve soft and hard tissue esthetics,3,6,7,10,12,15,47 and
46
average width of the buccal bone is about 0.6 mm. Thus, the bone to reduce the necessity for other surgical interventions such as ridge
modeling that takes place after tooth extraction at the buccal augmentation.5,7–12,15 Furthermore, it was also demonstrated that
174 | ARAÚJO ET AL.

immediate implant should only be indicated when primary stability is in 3P3 and 4P4 regions, the distal roots were removed. In one quad-
deemed possible during fixture installation.3,6,11 rant, implants were placed in the fresh extraction sockets, while in
Some of the clinical reports performed in Latin America on the contralateral side of the mandible the corresponding sockets
immediate implant are described below. In the study by Vergara and were left for spontaneous healing. After three months, biopsies of
Caffesse,15 16 maxillary single‐rooted teeth were carefully extracted the experimental sites were prepared for histological examination.
through a periotome and flapless technique and implants were The results obtained from histometric measurements demonstrated
immediately installed. The patients were re‐evaluated 12 months that at both experimental sites a marked dimensional reduction had
after the final restoration was delivered. The authors reported that occurred in the alveolar ridge. Thus, the placement of an implant in
there were some implant complications during 12‐month follow‐up, the fresh extraction site had failed to prevent the bone modeling
ie, marginal gingival inflammation (six sites), suppuration (one site), that occurred in the walls of the socket (Figure 4).
loosening of the abutment (three sites), and implant loss (one site). The following year, the Araújo et al34,35 groups published the two
The authors also measured through subjective scales the esthetic remaining experimental studies, which addressed two pivotal aspects
outcome of the experimental treatment protocol and suggested that of the immediate implant installation: the role of (i) early osseointe-
this protocol maintained soft tissue architecture, minimized alveolar gration, and (ii) socket dimension.34,35 In the second series of studies,
bone changes, and optimized the time to rehabilitation in a short‐ the authors used a methodology previously described in Araújo and
term follow‐up. A similar clinical prospective study was conducted Lindhe17 to evaluate whether osseointegration once established fol-
12
by Tortamano et al. The authors evaluated 12 patients who were lowing implant placement in a fresh extraction socket may be lost as
scheduled for extraction of one of the maxillary central incisors fol- a result of tissue modeling. In brief, mandibular premolars were
lowed by immediate implant and provisional prosthesis installation. extracted and implants immediately installed. Biopsies representing
The findings observed after the 18‐month period of the study different periods of healing were obtained for histological analysis at
showed that none of the implants or prostheses failed and that no zero, four, and 12 weeks. It was observed that at zero weeks the gap
peri‐implant soft tissue recession occurred. The authors concluded between the marginal portions of the implant and the walls of the
that immediate implants associated with provisional restorations fresh socket became filled with a coagulum. At the 4‐week time inter-
could be a predictable option for the replacement of missing teeth val, the coagulum had been replaced by newly formed bone that
when socket bone walls were intact. These findings were in agree- made direct contact with the implant surface. In addition, during the
ment with other studies performed in Latin America.6,11 first four weeks of healing (i) the buccal and lingual bone walls under-
It has also been examined if immediate implant installation could went pronounced surface resorption, (ii) the bundle bone in the mar-
be successfully performed at the posterior regions of the jaws. Case ginal region was resorbed, and (iii) the height of the thin buccal hard
13 10
series reports from Vergara and Caffesse, Oliveira et al and
Bersani et al5 addressed this hypothesis. Vergara and Caffesse13
evaluated implant installations in fresh extraction sockets of maxil-
lary molars in eight patients. Osteotomes were used to prepare the
surgical bed and screw‐type wide diameter implants were installed.
In addition, in six out of eight cases, an autograft or xenograft was
used to fill the remaining gaps between bone walls and implant
surface. The temporary crowns were delivered six to eight months
after implant installation. The authors reported that all cases, except
one, exhibited excellent healing outcomes, and none of them
required implant removal. Similar results were also obtained by Oli-
veira et al10 and Bersani et al5 Although some of the clinical reports
above suggest that immediate implant placement may prevent
dimensional ridge alterations, clinical studies from European research
groups that performed re‐entry bone measurements at immediate
implant sites demonstrated that a marked reduction of the alveolar
ridge had occurred following four months of healing.48–51
The dimensional alterations in the alveolar bone after immediate
implant installation were thoroughly addressed by several experi-
mental studies carried out in Latin America.17,21,32–40 In 2005, Araújo
and Lindhe17 presented the first experiment of a series of three that
F I G U R E 4 Microphotograph of a buccal‐lingual section
initiated a deep discussion on the fate of the socket walls. Their
representing a healed extraction socket four months after immediate
studies were heavily based on previous experiments they had per- implant placement. Note that the marginal portion of the buccal wall
formed in which they described the socket healing.17,21,32–40 In the is markedly resorbed. I, implant; L, lingual bone wall; PM, peri‐
first study,17 five beagle dogs were included. Following flap elevation implant mucosa. Ladewig fibrin stain, original magnification × 50
ARAÚJO ET AL. | 175

tissue wall was noticeably reduced. At the 12‐week time interval, it
was found that the process of healing was ongoing and that the
height of the buccal bone crest was further reduced. The authors
concluded that the early osseointegration that was established during
the early phase of socket healing following implant installation was in
part lost when the buccal bone wall underwent resorption.
In the third and final study,35 the authors examined whether the
reduction of the alveolar ridge that occurs following tooth extraction
and implant placement is influenced by the size of the hard tissue
walls of the socket. The methodology was similar to their previous
studies but the implants were placed in fresh sockets that exhibited
thin (premolar sites) and thick (molar sites) buccal bone walls. In addi-
tion, the premolar and molar sites were, respectively, characterized
by the occurrence of a narrow and a large gap between the implant
surface and the inner buccal socket wall. The sockets were allowed
to heal for 30 and 90 days. The histological analysis of the healed
sockets demonstrated that marked bone reduction had occurred in
both experimental groups of sockets but it had less effect on the
buccal level of bone‐to‐implant contact at the molar sites than at the
premolar sites (0.8 vs 2 mm of exposed sandblasted and acid‐etched
surface).
In summary, the studies from the Araújo et al33–35 groups
showed that immediate implant installation failed to prevent dimen-
sional reduction of the alveolar bone and buccal bone loss. They also
demonstrated that the thinner a socket bone wall is and the closer
to this wall the implant is installed, the higher the risk of compro-
mised healing and occurrence of bone dehiscence (Figure 4). Thus,
the placement of implants in fresh extraction sockets in the anterior
zone may represent an esthetic risk in esthetically demanding cases
since gingival recession, gingival discoloration, reduced buccal tissue
volume, and other unfavorable outcomes may occur at the site of
implant placement (Figure 5).
In the following years, several experimental studies in the dog
model carried out in Latin America evaluated whether different sur-
gical protocols and implant characteristics could prevent dimensional
periapical or periodontal disease, granuloma or cyst at the time of
tooth extraction and implant installation did not affect the healing
process when compared to healthy sockets when appropriate infec-
tion control measures were taken.6,27,28,41
Regenerative procedures as part of the tooth extraction and
immediate implant procedure were studied by Araújo et al32 and
Caneva et al36 to determine whether such surgical approaches could
change the process of post‐extraction bone modeling. It was
observed that the placement of a xenogenic graft in the void that
occurred between the implant and the walls of the fresh extraction
socket provided additional amounts of hard tissue at the entrance of
the previous socket and improved the level of marginal bone‐to‐
implant contact.32 Likewise, the use of a collagen membrane to
cover the entrance of the fresh extraction socket after implant
installation also contributed to the maintenance of the alveolar bone
contour.37 Recently, the benefit of the association between xeno-
genic graft and collagen membrane at immediate implant installation
sites was studied by Caneva et al.37 The results showed that
F I G U R E 5 Clinical photography of a dentition five years after
immediate implant placement at the maxillary right lateral incisor
site. Note the evident discoloration and marginal recession of the
soft peri‐implant tissues

alterations after immediate implant placement.20–22,31,32,37–40

3.1 | Surgical protocols

The surgical technique for tooth extraction and immediate implant
placement was assessed in terms of flap management, number of
extracted teeth, implant position, combination with regenerative pro-
cedures, and presence of socket infection. The effect of flap elevation
during immediate implant installation was addressed by Caneva et
al.21 The authors observed that after four months of healing both flap
and flapless approaches failed to prevent alveolar bone resorption and
that there were no significant differences between the two groups.
Other studies on the surgical protocols showed that multiple F I G U R E 6 Clinical photography of anterior region of the maxilla.
tooth extractions before immediate implant installation promoted On both sides of the maxilla, the lateral incisors were extracted and
implants immediately placed. The socket of the right lateral incisor
more alveolar bone loss than single tooth extraction40 while a more
was, however, grafted with bone substitute and connective tissue,
lingual implant position decreased bone dehiscence at the buccal while at the contralateral no graft was placed. Note the marked
aspect of the implant.22,40 Furthermore, it was also demonstrated reduction of tissue volume and the discoloration at the left lateral
that the presence of dentoalveolar pathology such as chronic incisor site (nongrafted)
176 | ARAÚJO
following four months of healing the sites with the regenerative pro-
cedure had less buccal bone loss than sites where no regenerative
procedure was performed. These findings were also supported by
case reports in Latin America.4,8,9 Thus, the use of a xenogenic graft
associated or not with a membrane appears to contribute to the
maintenance of the alveolar ridge dimension (Figure 6).
3.2 | Implant characteristics
Two implant characteristics have been evaluated by Latin American
experimental studies on immediate implant installation, diameter, and
surface. Evidently, the implant diameter influences the distance
between the implant surface and the outer surface of the buccal
socket wall, which eventually undergoes bone modeling during heal-
ing. Thus, the effect of the use of narrow or wide diameter implants
(3.3 vs 5.0 mm) for immediate implant installation on the amount of
buccal bone dehiscence was evaluated.20,38 The results of the stud-
ies referred above demonstrated that, when placed in fresh extrac-
tion sockets, wide diameter implants were associated with more
buccal bone dehiscence than narrow diameter implants. On the
other hand, studies that evaluated the tissue response to different
implant surfaces of implants inserted in fresh extraction sockets
failed to observed significant difference on the amount of bone‐to‐
implant contact.29,31
4 | CONCLUSION
Clinical and experimental studies performed in Latin America have
significantly contributed to the understanding of the socket healing
process with or without immediate implant placement. Essential
aspects of tissue formation and resorption were elucidated that
helped the development of more effective and predictable surgical
protocols for immediate implant placement and management of the
alveolar socket. Latin American studies demonstrated that immediate
implant installation was conducive for predictable osseointegration
and high survival rates but failed to prevent bone modeling and
dimensional reduction of the alveolar ridge. In addition, it was also
shown that regenerative approaches, including hard and soft tissue
grafts at the time of immediate implant placement, may be beneficial
to compensate for the alveolar ridge reduction. However, a system-
atic review including 46 prospective studies with a mean follow‐up
time of 2 years demonstrated that the success of implants placed
immediately into fresh extraction sockets was difficult to assess
because of a limited number of studies reporting biological, technical
and esthetic complications.1 Thus, more studies on this important
subject either performed in Latin American or elsewhere are
necessary.
ACKNOWLEDGMENTS
We thank Dr. Wagner Duarte for assistance with reviewing the
manuscript.
ET AL.
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2012;23(Suppl 5):39‐66.
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How to cite this article: Araújo MG, Silva CO, Souza AB,
Sukekava F. Socket healing with and without immediate
implant placement. Periodontol 2000. 2019;79:168–177.
https://doi.org/10.1111/prd.12252