DOI: 10.1111/prd.
12253
REVIEW ARTICLE
Implant placement in fresh extraction sockets
Juan Blanco | Cristina Carral | Olalla Argibay | Antonio Liñares
Unit of Periodontology, Department of Estomatology, Santiago de Compostela University, Santiago de Compostela, Spain
Correspondence
Juan Blanco, Department of Stomatology, University of Santiago de Compostela, Santiago de Compostela, Spain.
Email: jblanco@blancoramos.net
1 | INTRODUCTION
In the last decades, dental implants have been the treatment of
choice to replace missing teeth, with good long‐term prognosis.1-3
Advances have been achieved on bone healing, reducing the
osseointegration process and, consequently, the loading protocol
4,5
from classic periods of 3‐6 months to 6‐8 weeks. Implant surface
microtexture has speeded up the osseointegration process6 and
recently implant surface biochemistry has improved early bone heal-
ing at implant sites with adequate bone volume7 and, moreover,
spontaneous bone regeneration at peri‐implant defects.8,9
A different scenario is to replace failing teeth instead of
healed sites. Classic protocols of implant installation usually wait
12 months or longer for bone healing following tooth extraction
to place a dental implant.4 However, socket‐healing studies have
10,11
shown that after 3‐4 months the socket is filled by newly
formed bone and a dental implant can be placed under good con-
ditions in order to achieve primary stability. Losing anterior teeth
has a negative impact on esthetics and patient satisfaction.12
13
According to the systematic review by Esposito et al, patients
prefer short treatment protocols than conventional implant place-
ment with a delayed approach. Thus, in patients losing anterior
teeth, short treatment protocols may be preferable to a delayed
approach. In fact, many publications have proposed reduced treat-
ment time protocols in failing dentitions by placing implants into
fresh extraction sockets.
A classification system for the timing of implant placement after
tooth extraction was proposed at the Third ITI Consensus Confer-
ence.14 This classification system is based on the desired clinical out-
come of the wound‐healing process, rather than on descriptive terms
or rigid time frames following extraction:
• Type 1 placement refers to the placement of an implant on the
day of tooth extraction and within the same surgical procedure.
• Type 2 refers to implant placement after soft-tissue healing, but
before any clinically significant bone fill occurs within the socket.
Periodontology 2000. 2019;79:151–167. wileyonlinelibrary.com/journal/prd
• Type 3 placement describes implant placement following signifi-
cant clinical and/or radiographic bone fill of the socket.
• Type 4 placement refers to the insertion of an implant in a fully
healed site.
Typically, between 4 and 8 weeks of healing are required for
adequate soft‐tissue healing for early placement (type 2). For early
placement with partial bone healing (type 3), a healing period of
12‐16 weeks is usually needed. The time for healing and for
achieving the desired clinical outcome for type 2 and type 3
placement depends on the initial condition of the extraction site
and the dimensions of the socket. For late placement (type 4)
healing, 16 weeks or longer are usually required for complete
healing of the bone.
Since the first published work on implants into fresh extraction
sockets, the interest for this technique has increased.15 The advan-
tages are evident: a decrease in the number of surgeries and of the
overall treatment time,16,17 ideal implant orientation,15,18 bone
19-21
preservation in the extraction area and optimum esthetics of
18
the soft tissues. Moreover, recent systematic reviews have shown
that the survival rate of type 1 implant placement is similar to those
with a delayed approach.13,22,23 However, under certain conditions,
preclinical models and human studies have shown that immediate
implant placement per se does not preserve the anatomy of the
alveolus, mainly at the buccal bone crest, leading to bony dehis-
cences and subsequently to soft‐tissue recession, with a great impact
on esthetic outcomes.24-28
On the other hand, preclinical and human studies have identified
factors that may prevent bone resorption after immediate implant
placement, such as the size of the alveolus,24 thickness of the buccal
bone plate,24,29 buccal void dimension,29,30 flapless procedures,31
implant diameter,30 implant positioning,26,32 use of bone grafts,33
use of connective tissue grafts34 and use of provisional restora-
tions.35 In fact, different systematic reviews have shown improved
esthetic conditions with immediate implant placement and provision-
alization in comparison with standard protocols.23,36
© 2019 John Wiley & Sons A/S. | 151
Published by John Wiley & Sons Ltd
152 | BLANCO
2 | WHAT ARE THE SURVIVAL AND
SUCCESS RATES OF IMPLANTS PLACED IN
FRESH EXTRACTION SOCKETS?
Immediate implant placement is now a common procedure in daily
clinical practice, especially because treatment time is reduced
(Tables 1 and 2). However, there are some disadvantages inherent to
this procedure, such as more difficult closure of the flap, because of
the potential lack of keratinized mucosa; more difficult attainment of
primary stability, because of the discrepancy between the implant
dimension and the extraction socket; esthetic complications as a
consequence of soft‐ and hard‐tissue changes following immediate
implant placement. Chen and Buser22 published the first systematic
review on the survival and success rates of type 1, 2 and 3 implant
placement. Studies with a mean follow‐up period of at least
12 months from the time of implant placement were included.
Ninety‐one studies met the inclusion criteria. The authors found that
most of the studies reported survival rates of over 95%. Similar sur-
vival rates were observed for immediate (type 1) and early (type 2)
placement. In a recent systematic review, the survival rate of type 1
23
placement was evaluated. This systematic review included 46
prospective studies (10 randomized controlled trials) and provided
data on 2098 implants with a mean follow‐up period of 2 years. The
estimated 2‐year survival rate was 98.4% (confidence interval [CI]
97.3%‐99%). Survival was defined as implants remaining in situ dur-
ing the follow‐up examinations, irrespective of their conditions. Fail-
ure was defined as implants that were lost. Five factors were
investigated for their impact on the survival of immediate implants:
use of antibiotics, reason for extraction, location of implants (anterior
vs posterior, maxillary vs mandibular) and timing of restoration.
Among the five factors analyzed, only the regimen of antibiotic used
affected the survival rate significantly. The authors found that the
annual failure rate in patients who received only a single dose of
antibiotic preoperatively was statistically significantly higher (1.78%)
than the annual failure rate in subjects who received the 5‐7 day
postoperative course of antibiotics (0.51%) or a single dose pre‐ and
5‐7 days postoperative (0.75%), irrespective of the antibiotic used. In
fact, in a retrospective study in which a total of 1925 immediate
implants were studied to evaluate implant survival rates and to
determine risk factors for implant failure, patients who could not use
postsurgical amoxicillin (allergic patients) were 3.34 times more likely
to experience implant failures than patients who received amoxi-
cillin.37 In a review, Renvert and Persson38 indicated that subjects
with a history of periodontitis might have a greater risk of peri‐
implant infections. However, a recent systematic review23 failed to
support this fact in immediate implants, due to the lack of prospec-
tive studies reporting data on a group of subjects with teeth
extracted only for periodontal reasons. The position of implants was
not statistically different in relation to survival rates comparing max-
illa and mandible or anterior and posterior locations. In the 46 stud-
ies included in that systematic review, 967 implants were placed in
the posterior area and 487 in the anterior. Although the authors
observed that the estimated annual failure rate might be higher in
ET AL.
implants placed in the posterior region, the difference was not statis-
tically significant. Similar results were observed with regards to the
maxillary or mandibular position of the implants; although maxillary
implants seemed to have a slightly higher rate of annual implant fail-
ure, statistically significant differences were not found.23
The systematic review by Lang et al23 corroborated the findings
by Gallucci et al.39 Both did not observe statistical differences with
regards to survival rates of immediately loaded or conventionally
loaded implants. However, Atieh et al,40 in their systematic review
and meta‐analysis, achieved better results using conventional loading
compared with immediate loading on single implants. Slagter et al36
published a recent systematic review that assessed implant survival,
peri‐implant hard‐ and soft‐tissue changes, esthetic outcomes and
patient satisfaction of immediately placed single‐tooth implants in
the esthetic zone. The 34 studies included showed that the 1‐year
survival rate of single immediate implant placement in the esthetic
zone was 97.1%. These results were similar to the previously
reported systematic review.23 Thus, the short‐term survival rate of
type 1 implant placement is similar to that of implants placed in
healed sites with longer follow‐up.1-3 Today is quite clear that
implant performance should be assessed in terms of success rather
on survival rates. A successful implant means the absence of any
biological, technical or esthetic complications.
2.1 | Biological complications
Biological complications include peri‐implant mucositis and peri‐
implantitis. The consensus report of the Sixth European Workshop
on Periodontology defined peri‐implant mucositis and peri‐implantitis
as infectious diseases. Whereas peri‐implant mucositis describes an
inflammatory lesion that resides in the mucosa, peri‐implantitis also
affects the supporting bone.41 The prevalence of peri‐implant infec-
tions is difficult to determine because of the multicausality of factors
and the number of implant systems available on the market. In a
review, Zitzmann and Berglundh42 reported data from cross‐sectional
and longitudinal studies that included more than 50 implant‐treated
patients exhibiting a function time of more than 5 years. The authors
showed that peri‐implant mucositis occurred in approximately 80%
of the patients and 50% of the implants. Peri‐implantitis was found
in 28%–56% of the patients and in 12%–43% of the implants. In a
recent review by Mombelli et al,43 peri‐implantitis was found with a
prevalence in the order of 10% of the implants and 20% of the
patients during 5‐10 years after implant placement.
The diagnosis of peri‐implant diseases requires assessment of the
presence or absence of bleeding on probing in the peri‐implant soft
tissues and changes in the level of crestal bone.44 In the systematic
review by Lang et al23, biological complications were evaluated in
nine studies with a mean follow‐up of 3 years or more. However,
seven assessed radiographic bone changes but only three of them
reported clinical data of the peri‐implant soft‐tissue response to peri-
odontal probing.45-47 In a controlled trial, Bianchi and Sanfilippo45
compared clinical and radiographic data on implants placed in fresh
extraction sockets with or without a subepithelial connective tissue
BLANCO ET AL. | 153

TABLE 1 Survival and success rates in type 1 implant placement

Immediate/
Type Follow‐ Patients/ Implant Flap/ Grafting delayed Survival Success
Authors of study up implants position Groups flapless material restoration rate rate
Bianchi and RCT 1‐9 yr 116/116 Maxilla/ T: Connective NR T: Connective Delayed 100% NR
Sanfilippo mandible graft graft
(2004)45 C: None C: None
Covani et al Cohort study 4 yr 95/163 Maxilla/ T: GBR Flap T: GBR Delayed 100% 97%
(2004)49,51 mandible C: None C: None
Chen et al RCT 3 yr 30/30 Maxilla T: Bio‐Oss ± Bio‐ Flap T: Bio‐ Delayed NR NR
(2007)76 Gide Oss ± Bio‐
Gide
C: None C: None
Botticelli Cohort study 5 yr 18/18 Maxilla/ None Flap None Delayed 100% NR
et al mandible
(2008)46
De Rouck RCT 12 mo 49/49 Maxilla T: Immediate Flap T: Bio‐Oss Immediate 96% NR
et al restoration
(2009)35 C: Delayed C: Bio‐Oss + Delayed 92%
restoration Bio‐Gide
Cordaro et al RCT 12 mo 30/30 Maxilla/ T: Nonsubmerged Flap NR Delayed 93.80% NR
(2009)60 (multicenter) mandible C: Submerged 100%
Canullo et al RCT 25 mo 22/22 Maxilla T: Platform Flapless NR Immediate NR NR
(2009)58 switching
C: Nonplatform
switching
Prosper et al Cohort study 5 yr 71/120 Mandible T: Immediate Flap NR Immediate 96.70% NR
(2010)47 restoration
C: Delayed Delayed
restoration
Raes et al Case series 52 wk 39/39 Maxilla T: Immediate Flap/ T: None Immediate 93.80% NR
(2011)59 implant flapless
C: Delayed Flap NR Delayed 100%
implant
Kan et al Case series 4 yr 35/35 Maxilla A: Thin biotype Flapless C: NR Immediate NR 100%
(2011)85 (2‐8.2 yr) B: Thick biotype
Rodrigo et al Cohort study 5 yr 22/68 NR T: Immediate NR T: Immediate/ 100% 73.60%
(2012)50 implants Gap > 2 mm delayed
D: Delayed C: NR 76.50%
implants
Sanz et al RCT 3 yr 93/99 Maxilla A: Cylindrical Flap None Delayed 98.90% NR
(2014)52 (multicenter) implants
B: Cylindrical‐
conical implants

RCT, randomized controlled trial; NR, not reported; T, test; C, control;

GBR, guided bone regeneration
Bio‐Oss
Bio‐Gide

graft. After 1‐9 years of observation, 31% of implants presented
with peri‐implant mucositis. Another two studies reported less
prevalence of peri‐implant mucositis.46,47 The seven studies that
described hard‐tissue conditions reported marginal bone loss that
generally fulfilled the success criteria stated by Albrektsson et al,48
that is, marginal bone loss <0.2 mm after the first year of service.
Covani et al49 showed an unusual amount of marginal bone loss in
4.3% of implants, but in the absence of reporting bleeding on prob-
ing it was difficult to estimate the prevalence of peri‐implantitis, con-
cluding that future research should pay more attention to evaluating
peri‐implant tissues by periodontal probing and radiographs. Rodrigo
et al,50 in a 5‐year prospective cohort study, evaluated the biological
154 | BLANCO ET AL.

TABLE 2 Biological, technical and esthetical complications in type 1 implant placement

Type of Patients/ Implant Biological
Authors study Follow‐up implants position complication Technical complication Esthetical complication
Bianchi and RCT 1‐9 yr 116/116 Maxilla/ 30% mucositis NR Recession ≥1 mm in
Sanfilippo mandible the control group at
(2004)45 the 0‐3 yr observation
period
Covani et al Cohort study 4 yr 95/463 Maxilla/ NR 9.8% loosening the screw NR
(2004)49,51 mandible
Chen et al RCT 3 yr 30/30 Maxilla NR NR 3.3% recession ≥1 mm
(2007)76
Botticelli Cohort study 5 yr 18/18 Maxilla/ 15%‐20% NR NR
et al mandible mucositis
(2008)46
De Rouck RCT 12 mo 49/49 Maxilla NR NR Recession 2.5‐3 higher
et al delayed vs immediate
(2009)35 restoration
Cordaro et al RCT 12 mo 30/30 Maxilla/ NR NR Keratinized mucosa
(2009)60 (multicenter) mandible reduction 1.3 vs 0.2
submerged vs not
submerged group
Canullo et al RCT 25 mo 22/22 Maxilla NR NR Recession +0.0 vs −0.45
(2009)58 platform‐switching vs
not platform‐switching
group
Prosper et al Cohort study 5 yr 71/120 Mandible NR NR NR
(2010)47
Raes et al Case series 52 wk 39/39 Maxilla NR NR 7% recession ≥1 mm
(2011)59 immediate implants
Kan et al Case series 4 yr (2‐8.2 yr) 35/35 Maxilla NR NR Mean facial recession
(2011)85 1.13 mm
Rodrigo et al Cohort study 5 yr 22/68 NR 20% mucositis; NR NR
(2012)50 5.8% peri‐
implantitis
Sanz et al RCT 3 yr 93/99 Maxilla 2 patients 2 patients reported None
(2014)52 (multicenter) reported loosening or fracture of the
inflammation, 1 abutment, 2 patients
pain and 3 reported washout of the
infection definitive crown

RCT, randomized controlled trial; NR, not reported.

complications of immediately placed implants when compared with
similar implants installed with a delayed protocol in the same
patients. They observed a higher tendency to crestal bone loss and
peri‐implantitis in type 1 placement, but without statistically signifi-
cant differences between groups. On the other hand, in a prospec-
tive 5‐year follow‐up clinical and radiographic study, Botticelli et al46
observed that immediate implants with delayed load maintained or
even improved the mean radiographic bone level (mean 0.2 mm) dur-
ing the 5‐year observation period.
2.2 | Technical complications
Although technical complications are frequent in implant‐supported
2
prosthesis as, reported by Pjetursson et al in their systematic
review, these are not commonly reported in studies with long‐
term follow‐up in type 1 implant placements. Technical complica-
tions would include fracture of the implant, loss of retention,
screw/abutment loosening, loss of access to hole restoration, frac-
ture of abutment or screws and fracture of covering materials of
the prosthesis. Lang et al23 assessed technical complications in
their systematic review. However, only three studies with an
observation period ≥3 years reported data about this complication.
The only prosthetic complication that occurred (9.8% of implants)
was loosening of the abutment screw reported in the 4‐year study
by Covani et al.51 The other two studies were free of complica-
tions. These findings are comparable with those reported by Jung
et al1 in a systematic review providing data for 26 articles about
the incidence of technical complications on implant‐supported
BLANCO ET AL.
single crowns, where they observed a cumulative incidence of
screw or abutment loosening of 12.7% and 0.35% for screw or
abutment fracture after 5 years.
2.3 | Esthetic complications
The installation of implants into fresh extraction sockets has proved
to be a reliable procedure. However, this procedure is associated
25,31
with partial resorption of the buccal bone wall, resulting in a
compromising esthetic outcome.26 Therefore, the success of immedi-
ate implants should not be limited to osseointegration; stable peri‐
implant soft tissue should be an objective in order to achieve
esthetic success. In the systematic review by Lang et al23 only two
of 46 studies evaluated the esthetic results.45,46 In the randomized
clinical trial by Bianchi and Sanfilippo,45 which compared soft‐tissue
behavior around immediate implants with or without a connective
tissue graft, there was total success for the first 3 years in the group
of patients receiving a connective graft (test group), whereas 80% of
cases in the control group were considered successful. In a longer
follow‐up (3‐9 years), mucosal recession >1 mm was observed in
some patients. However, the position of the soft tissue was gener-
ally stable when the connective tissue graft was placed.45 The study
by Botticelli et al46 also evaluated the position of the mucosal mar-
gin during a 5‐year follow‐up period and observed a soft‐tissue
recession on the buccal aspect of the restorations in five of 21 sites
(24%). Therefore, 20%‐25% of patients treated with immediate
implants showed esthetic problems (recession), although the soft tis-
sues appeared to be stable in the long‐term evaluation period
(≥3 years) in most patients. These data are consistent with the study
by Sanz et al,52 where 80% of all sites analyzed showed no recession
after an observation period of 3 years. However, due to the limited
number of long‐term studies, it is difficult to establish the prevalence
of esthetic complications and investigate factors influencing the
esthetic outcome (immediate restoration, flap vs flapless, implant
position). Based on two prospective studies53,54 and a randomized
clinical trial,35 Lang et al23 provided data on the soft‐tissue level
changes at 3, 6 and 12 months following immediate implants with
immediate provisional restorations in relation to the preoperative
status in the anterior maxilla. The review concluded that most of the
soft‐tissue changes occurred in the first 3 months and that mesial
and distal papilla decreased in size during the first year.23 In a recent
publication, Kan et al 55
followed up the same patient population as a
study published in 2003. They observed that papillae may have the
capacity to regrow over time following implant restoration, which
seems to be independent of gingival biotype. In another study by
56
Kan et al, the distribution of papillae fill during the first year fol-
lowing immediate implant placement and immediate restoration was
investigated. In more than 90% of the implants they observed a
papilla index score 2, where the papilla was greater than half the
height of the proximal space, or 3 (the papilla fills the entire proximal
space) at every examination visit. The number of papillae achieving
score 3 continued to increase from implant placement and provi-
sional insertion up to 6 months, gaining the papillae stability
| 155
afterwards.56 These results are in agreement with a recently pub-
lished study by Sanz et al,52 who reported that, although immedi-
ately after the definitive prosthesis was placed the degree of
papillae was poor (score 1), at 3 years approximately 25% of the
gaps were completely filled with soft tissue, whereas only 12%‐23%
received score 1; the increase in soft‐tissue dimension of the papillae
was more pronounced during the first 2 years, but remained
unchanged between the second and third years.52 In a recent sys-
tematic review based on 13 studies, four randomized controlled tri-
als and nine case series, Cosyn et al57 assessed the frequency of
advanced recession (≥1 mm) and considered some potential risk fac-
tors in the esthetic outcome following immediate implant placement.
They concluded that the advanced retraction frequency is <10% in
cases with an intact buccal bone plate and thick biotype treated with
flapless surgery and immediate prosthesis.
A randomized controlled trial demonstrated a preserving effect
of immediate loading on buccal mucosa level. In the control group of
the study by De Rouck et al,35 in which provisional prosthesis was
delayed, papillae shrinkage and buccal recession were higher than in
the test group (immediate loading) at the 3‐month follow‐up. At the
12‐month re‐examination the two groups showed comparable results
in papillary height. However, the differences in the position of the
buccal mucosa persisted during the 1‐year observation period and
recession was two to three times higher in the control group
(1.16 mm) vs the immediate loading group (0.41 mm).35 Three stud-
ies indicated a frequency of <10% of advanced recession in cases
where the prosthesis was placed immediately.57-59 These results are
similar to the study by Cordaro et al,60 whose conclusion was that
the greatest loss was recorded at the time of provisional restoration,
which was carried out 3 months after implant installation, but in the
following 12 months minimal changes were recorded.
3 | WHAT ARE THE ANATOMICAL AND
SURGICAL/RESTORATIVE FACTORS THAT
MAY AFFECT CLINICAL OUTCOMES?
3.1 | Anatomical factors
3.1.1 | The alveolus
The external dimensions of the alveolar ridge are reduced following
tooth extraction61-63 (Table 3). Different retrospective clinical64-66
and prospective studies67 have shown important dimensional
changes (reductions in the height and width of the alveolar crest)
following tooth extraction as a result of bone modeling. In a
prospective clinical study, about 50% of the width of the ridge in
posterior sites was lost after a healing period of 12 months and two‐
thirds of this loss occurred within the first 3 months.67 The resorp-
tion of the buccal bone plate is seemingly more significant than that
of the lingual/palatal bone plate.65 In an experimental study it was
reported that the facial bone wall is thinner than the lingual bone
wall and is composed almost entirely of bundle bone in the coronal
region. Thus, resorption is the result of replacement of bundle bone
156 | BLANCO ET AL.

TABLE 3 Factors affecting ridge alterations following immediate implant placement

Human Animal
studies studies Agreement Disagreement Comments and clinical recommendations
Anatomical factors
Thickness of the 29, 75, 77, 78 29, 75, 77, 78 If buccal bone plate thickness is <2 mm, vertical bone
buccal bone resorption can be expected, thus consider DP. If IP is
plate decided, the buccal void should be filled with a bone
graft (slow resorption material)
Dimension of the 9, 29, 102 28, 30-33, 9, 28–33, 100 If implant was in contact with the buccal bone plate,
horizontal gap 100 vertical bone resorption could be anticipated. Consider
the use of smaller implant diameters than the alveolar
diameter at the bone crest
Dehiscence 80-82 80-82 Resorption was greater in the presence of a dehiscence
defect defect compared with sites with intact facial bone.
Consider DP with or without socket preservation
Gingival biotype 22, 23, 26, 22, 23, 26, High risk of advanced gingival recession with negative
54, 60, 85 54, 60, 85 esthetic outcomes with thin gingival biotype. Consider
DP, if IP is decided soft‐tissue grafting may be
recommended
Presence 23, 36, 86, 88-92 23, 88–92, 86, 87 Chronic periapical/periodontal pathology may not be a
periapical/ 87, 93-95 94, 95 contraindication for IP if thorough debridement of the
periodontal socket is performed. Acute infections are contraindicated
pathology to IP
Surgical and restorative factors
Implant diameter 25, 30, 31 25, 30, 31 The use of wider implants that have contact with the
buccal bone wall increases the vertical bone loss.
Consider the use of smaller diameter implants
Implant position 26 32 26, 32 Buccal implant positioning has a higher risk of vertical
bone loss and soft‐tissue recession. Slight palatal position
is recommended
Flap vs flapless 59 24, 25, 31, 24, 25, 59, 31 There is a tendency of more buccal bone loss with a flap
surgery 68, 84 68, 84 procedure. Whenever possible a flapless procedure is
recommended
Bone graft 23 31, 33, 101, 31, 33, 101, 23 Filling the buccal void with a slowly resorbable bone graft
102 102 may prevent buccal bone loss, particularly when the
buccal bone plate is 1.5 mm or less
Connective tissue 36, 45, 103 34 34, 36, 45, Connective tissue grafting with an envelope technique
graft 103 may improve facial soft‐tissue stability and esthetic
outcomes. Soft‐tissue grafting may be recommended in
the esthetic zones
Platform‐ 58, 117 58, 117 Bone loss was more significant in platform‐matching
switching implants. Consider the use of platform‐switching implants
implants at IP
Immediate 23, 35, 36, 27, 115, 116 23, 27, 35, If a desirable primary stability is achieved, immediate
loading/ 40, 53, 55, 36, 40, 53, loading/provisionalization can be considered without
immediate 85, 113 55, 85, 113, affecting survival rates. The use of an immediate
provisionalization 115, 116 provisional restoration is recommended with IP

Agreement, studies that agree with the influence of the factor; disagreement, studies that disagree with the influence of the factor; DP, delay implant
placement; IP, immediate implant placement.

by woven bone from the inner portion and resorption of the outer
and crestal portions of the buccolingual socket walls. This takes
place during the first 8 weeks of healing.61 In fact, an experimental
68
model published by Vignoletti et al showed that buccal vertical
bone resorption occurred during the first week of healing. In that
study, implants were installed in postextraction sockets and sacrifice
of animals was at 4 hours, 1, 2, 4 and 8 weeks. The vertical loss at
the buccal aspect was 0.73 mm at 1 week, 0.77 at 2 weeks, 0.70 at
4 weeks and 0.73 at 8 weeks. On the lingual aspect there was no
vertical loss.68 This shows that in thin buccal plates composed
mainly of bundle bone, vertical resorption will be more pronounced
during the first week due to the loss of the bundle bone that is
inserted into the tooth through the periodontal ligament. A recent
systematic review evaluated the dimensional changes in the hard
BLANCO ET AL.
and soft tissues of the alveolar process up to 12 months following
tooth extraction. It was concluded that after 6 months of healing,
the vertical resorption of the alveolar bone was 11%‐22% and the
69
horizontal resorption of the alveolar bone was 29%‐63%. This pro-
cess of resorption and bone collapse, both vertically and horizontally,
could have negative consequences from a prosthetic and an esthetic
point of view and, in more advanced cases, could make it impossible
70
to place dental implants without bone regeneration. In order to
avoid this clinical situation, different authors have described different
regenerative techniques for socket preservation or immediate
implant placement.71
Several studies assessing ridge preservation techniques for main-
taining the dimensions of the bone after tooth extraction have
shown that despite the use of barrier membranes or bone grafts,
horizontal resorption of 13%‐25% still occurred.72,73 Recent experi-
mental25,30,31,68 and clinical29,49,74,75 studies have confirmed that
implants placed immediately into extraction sockets will not prevent
the occurrence of ridge alterations that apparently always take place
following tooth loss. In a prospective clinical study by Botticelli et
al,74 no bone fillers or barrier membranes were used with immediate
implants. After 4 months of submerged healing they observed that
56% horizontal resorption and 0.3 ± 0.6 mm vertical crestal resorp-
tion of the facial bone wall occurred. Other recent clinical studies
have shown similar results when no regeneration material was
49,76 28
used. Sanz et al, in a prospective randomized controlled clinical
study, evaluated bone preservation using two different implant con-
figurations into extraction sockets without regeneration. The results
showed marked alterations of the dimension of the ridge 4 months
later. For the cylindrical implants the reduction in the buccal ridge
was 43% and was 30% for the tapered implants. The reduction in
the height of the marginal bone crest was more pronounced on the
buccal than on the palatal aspect of the extraction site (1.0 vs
0.5 mm).
Factors affecting the modeling/remodeling process of the buccal
and lingual bony walls of extraction sockets are still uncertain. How-
ever, recent studies have reported that the thickness of the buccal
bone as well as the dimension of the horizontal gap (the space
between the inner part of the alveolar wall and the implant surface)
are two anatomical factors that influence the pattern of resorption
and bone modeling/remodeling that occur following immediate
implant placement into extraction sockets.29,75,77 There appears to
be general agreement that the minimum width of bone that must
surround an implant placed in healed bone should be 2 mm to main-
tain the vertical height of the bone crest at that level.77,78 In the
context of immediate implants, the width of the buccal plate of the
extraction socket is a relevant factor in the pattern of resorption and
bone modeling and the thickness of the buccal crest significantly
influences not only the amount of horizontal gap fill but also the
amount of vertical crestal resorption.29,75,77 Thus, the wider the buc-
cal bone, the greater the fill of the buccal void and the less vertical
resorption of the buccal crest. However, 87% of the buccal bony
walls (anterior teeth) had a width ≤1 mm and 3% of the walls were
2 mm wide. On posterior sites, the corresponding values were 59%
| 157
and 9%, respectively.29,79 For this reason, and considering that most
agree that a minimum thickness of 2 mm of buccal plate is needed
to avoid collapse after tooth extraction, regeneration techniques
and/or soft‐tissue grafts are important to achieve adequate bony
contours around the implants.29,30,79 Chen et al76 placed 30 implants
in maxillary anterior extraction sockets in 30 patients. The gap
between the implant and the socket bone wall (mean value: 1.9 mm)
was randomly assigned to receive anorganic bovine bone with or
without a bioresorbable collagen membrane or no graft. When com-
pared with no graft, anorganic bovine bone was able to limit hori-
zontal ridge resorption but not the vertical resorption of the buccal
bone wall, concluding that the extent of vertical crestal resorption
was related to the initial thickness of the buccal bone.
Another factor that appears to be critical is the presence of a
dehiscence defect. In postextraction sites, loss of one or more of the
socket walls is a common observation.80 Chen et al81 conducted a
clinical study in which they could find no differences in terms of ver-
tical defect reduction between the control group (immediate
implants) and test groups (immediate implants with either a nonre-
sorbable membrane, a resorbable membrane, a resorbable membrane
with autograft bone or a bone autograft alone) with respect to the
dimensions of the ridge after 6 months of healing, in which many of
the immediate implants were placed in locations with dehiscence
defects. However, the results showed statistically significant differ-
ences in terms of horizontal resorption, which was 58% greater in
the presence of a dehiscence defect compared with sites with intact
facial bone. The horizontal resorption of facial bone was significantly
greater in the presence of a dehiscence defect compared with sites
with intact facial bone.
This factor is crucial when selecting the case, because patients
demonstrated a high risk of advanced gingival recession when dehis-
cence defects were present. Moreover, gingival recession seems
inevitable despite thick biotype, flapless surgery or connective tissue
graft.82
A number of recently published animal studies proved that after
dental extraction both healing and maturation of the alveolus occurred
despite placing immediate implants.13,25,31,68,83 These experimental
studies reported that a process of buccal bone resorption always
occured after tooth extraction when an implant was immediately
placed. The amount of buccal crest resorption ranged from 2.95 mm
to 0.8 mm. The amount of bone crest resorption reported by Araujo et
al84 was far less in the molar area than in the premolar area (1 mm of
buccal bone loss vs 2.1 mm). It seems that the dimensions of the
socket may play a role in the amount of bone loss following immediate
implant placement and the presence of a void between the implant
body and the inner part of the buccal bone plate at implant placement
may prevent further bone resorption.84
3.1.2 | Gingival biotype
Study of the soft tissues around osseointegrated implants has gained
importance over the last few years. It has been stated that midfacial
recession occurs relatively frequently following immediate implants.22
158 | BLANCO
For this reason, this complication has received attention recently
because it results in an unpleasant esthetic outcome.22,57 A thin gingi-
val biotype around the natural dentition and implants has been corre-
26,54
lated with a higher risk of gingival recession than a thick biotype.
This biotype reflects the limited underlying bone support. The buccal
bone plate is almost all bundle bone that is resorbed after tooth
loss25 and regardless of implant placement, midfacial recession may
85
be an expected consequence. In recent clinical studies, where
immediate implants in the esthetic zone were placed, reported
changes in the gingival level were between −0.53 and −0.8 mm, 1 or
2 years after implant surgery.53,54 In a recent clinical study, Kan et
85
al evaluated the amount of recession and reported statistically sig-
nificant differences in gingival level between thick and thin gingival
biotypes (−0.56 mm and −1.50 mm, respectively) after 2‐8 years.
These results are in accordance with those of Cordaro et al60 show-
ing advanced midfacial recession in 38% and 85% of patients with a
thick and thin‐scalloped gingival biotype, respectively. That effect of
gingival biotype on peri‐implant tissue response only seemed to be
limited to facial gingival recession and did not influence interproximal
papilla or proximal marginal bone levels.60 Those data were corrobo-
rated by a systematic review that reported an apical displacement at
the facial mucosa in patients with thin/thick gingival biotype of
1.50 mm vs 0.56 mm.23 A systematic review assessing clinical out-
comes with immediate, early and delayed implant placement con-
cluded that recession of the facial mucosal margin was common with
immediate placement (recession >1 mm was observed in 21.4% of
sites); risk indicators included thin biotype, facial malposition of the
implant and thin or damaged facial bone wall.22
Thus, it seems that a thin biotype is three times more prone to
midfacial recession after immediate implant placement, and that this
recession tends to be three times larger in thin than in thick gingival
biotypes.
3.1.3 | Periapical/periodontal pathology
Immediate implant placement had been contraindicated in the pres-
ence of periapical and periodontal lesions. 86,87
However, more recent
animal experiments have reported that osseointegration occurs in
sites with experimentally induced periapical and periodontal lesions,
as it does in healthy sites.88-92 A review by Waasdorp et al93 included
three experimental studies in a canine model where periapical and
periodontal infections were induced. The results showed that although
the percentage of bone‐to‐implant contact was lower in implants
placed in infected sites vs implants in healthy places, no implant fail-
ures were observed in any of the animal models. The data reported
from eight human studies indicated that survival rates for immediate
implants in infected places were near 100% (between 97.4% and
100%),93 similar to the rates reported by Lang et al23 for immediate
implants into fresh extraction sockets of 98.4% (97.3%‐99%) and by
36
Slagter et al (97.1%, 95% CI [0.958‐0.980]) for immediate implants
in the esthetic zone. Siegenthaler et al,94 in a controlled clinical trial,
evaluated the biological complications in soft and hard tissues of
immediate implants placed in extraction sockets of teeth exhibiting
ET AL.
periapical pathology. The results at 12 months showed a 100% sur-
vival rate and no statistically significant differences between test and
control groups (implants placed in extraction sockets without periapi-
cal pathology).94 The same group published the 5‐year data of this
study; the survival rate was 100% for all implants. Regarding esthetic
parameters, no differences were found between the 3‐month follow‐
up and the 5‐year follow‐up in both groups and the position of the
gingival margin at the implant site and the two neighboring teeth
remained stable. No peri‐implantitis lesions were detected in any of
the implants. Thus, this study shows that immediate implant place-
ment into extraction sockets exhibiting periapical pathology can be a
successful treatment modality in terms of clinical and esthetic parame-
ters.95 A recent systematic review analyzed outcomes of immediate
implant placement into sites presenting endodontic and periodontal
lesions. Twenty‐three articles met the inclusion criteria and showed
high survival. The authors stated that implants may be successfully
osseointegrated when placed immediately after extraction of teeth
with periodontal and/or periapical pathology, but taking adequate clin-
ical procedures before implant installation, such as thorough cleaning,
socket curettage/debridement and chlorhexidine irrigation.96 Further
limitation among the available literature was that definition of the
pathology with or without infection was often vague. Moreover, the
outcome measures analyzed were often not related to the type of
infection.
3.2 | Surgical and restorative factors
3.2.1 | Implant diameter and positioning
As mentioned above, the width of a void between the inner part of
the buccal bone wall and the implant surface may play a role in the
resolution of the defect. In fact, different results were obtained in
similar experimental models using different implant diameters. In the
beagle dog, Araujo et al25 installed implants with a 4.1 mm diameter
into extraction sockets of fourth and third premolars. The amount of
vertical buccal bone loss was 2.6 mm. A similar study by Blanco et
al31 comparing flap vs flapless procedures obtained a vertical buccal
bone loss of 1.3 mm in the flap group. In both studies the same
implant was used with the same healing time (3 months), but the
diameters were different (4.1 vs 3.3 mm). The dimensions of the
sockets measured before implant installation in both studies ranged
from 3.5 to 3.9 mm. Thus, in Araujo et al's research, the diameter of
the implant was wider than the socket at the coronal aspect, in par-
ticular in the mesial socket, which is slightly smaller.25 This observa-
tion was confirmed by Caneva et al,30 who installed implants with
different diameters into extraction sockets in Labrador dogs. After
4 months of healing, the test group (implant with a diameter the size
of the socket) showed 2.7 mm of vertical buccal bone loss, whereas
in the control group (implant with a narrow diameter) the vertical
buccal loss was 1.5 mm. Although a minimum of 1 mm of vertical
bone loss can be expected after immediate implant placement, the
use of wider implants that have contact with the buccal bone wall
increases the vertical bone loss two times.30
BLANCO ET AL.
Based on recently published data, vertical buccal bone loss can
be expected. However, on the lingual aspect bone loss is minimal.
Here, the thickness of the wall could play a role in preventing bone
loss. Thus, some authors advise placing the implant towards the
palatal/lingual bone wall and 1 mm below the coronal margin of the
buccal bone crest. Caneva et al32 studied the influence of implant
positioning on ridge alterations following immediate implant place-
ment in dogs. In the control group, implants were installed in the
center of the socket with the implant shoulder at the same level as
the buccal bone crest. In the test group, implants were placed
towards the lingual socket wall and 1 mm below the buccal bone
crest. The amount of vertical buccal bone loss was 2 mm in the con-
trol group and 1.4 mm in the test group. However, as the implant
was placed 1 mm below the buccal bone crest, only 0.4 mm dehis-
cence defect was found 4 months after implant installation. So, it
could be expected that in the control group the risk of soft‐tissue
32
recession was much higher than in the test group. In a human clin-
ical study, it was shown that the mean midbuccal recession
18 months after immediate implant placement in the esthetic zone
was 1 mm. However, the implants that were placed in a more palatal
position presented with a mean of 0.6 mm of recession in contrast
to the 1.8 mm in sites where implants were placed towards the buc-
cal crest.26
Thus, it seems clear from experimental and human clinical studies
that the implant body should avoid contact with the buccal bone.
This can be achieved with a more palatal position of the implant and
smaller diameter implants.
3.2.2 | Flap vs flapless
Most of the experimental studies on immediate implant placement
were performed raising a flap.24,25,68,84 In this context, the surgical
trauma must be highlighted – detachment of the periosteum from
the underneath bone surface – which will cause vascular damage
and an acute inflammatory response, triggering the resorption of the
exposed bone surface.97-99 This could partially explain the dimen-
61
sional alterations suffered by the alveolus after extraction, even if
an immediate implant is placed.25 Blanco et al31 showed in the bea-
gle dog that the resorption of the buccal bone after immediate
implant placement is reduced, but not statistically significantly, when
performed without raising a flap. The amount of buccal bone loss at
3 months was 1.33 mm in the flap group and 0.82 in the flapless
F I G U R E 1 Immediate implant
placement in the beagle dog. Flap (left) and
flapless surgery (right)
| 159
approach (Figures 1 and 2). On the other hand, other studies also
analyzed the ridge alterations following tooth extraction with or
without flap elevation and without immediate implant placement.
After 6 months, marked alterations of the ridge were reported, and
the procedure used for the extractions (flapless or flap elevation) did
not influence the bone‐healing outcome.31,100 Raes et al,59 in a 1‐
year case series study in humans, demonstrated significant less
recession when immediate implants were placed with a flapless
approach.
3.2.3 | Bone grafts
Many clinicians have been using grafting materials to fill the buccal
void after immediate implant placement. However, until 2011, no
experimental data were reported to assess the potential effect of
preventing buccal bone loss. Araujo et al33 published a beagle dog
study where implants were placed after tooth extraction. In the con-
trol group, a 3.3 mm diameter implant was placed, avoiding contact
with the buccal bone plate; in the test group, implant positioning
was the same as in the control group but the buccal void was filled
with deproteinized bovine bone mineral with a 10% porcine collagen.
After 6 months, the control group showed a vertical buccal bone
loss of 1.3 mm,33 similar to the results reported by Blanco et al.31
The test group with the grafting material showed that the buccal
bone crest was at the same level as it was at implant installation
with no vertical buccal bone loss. Thus, it seems that the grafting
material on the buccal bone gap prevented vertical bone loss.33
However, another study in the Labrador dog could not find a differ-
ence between grafted and nongrafted groups. Three months after
healing, the buccal bone crest was located at the same level as it
was at implant installation in both groups. Nevertheless, different
issues can be analyzed from this study. First, the model. The Labra-
dor dog is larger than a beagle dog and the dimensions of the socket
are wider in the premolar region than in the beagle dog (5 mm vs
3.5‐3.9 mm). Thus, in this study all implants presented a mean buccal
gap of 1.7 mm, as at the same time, implants were placed slightly
lingual. Another important factor is the thickness of the buccal bone
plate. In this model (Labrador dog) it was 1 mm at the crest and 1.4‐
1.6, 3 mm apically to the crest. The thickness of the buccal bone
plate in the beagle dog at the premolar mandibular area is thinner
than in the Labrador. Moreover, the length of the present study was
3 months compared with 6 months in the first study. Thus, it seems
160 | BLANCO
that the benefit of placing a bone graft in the buccal gap at immedi-
ate implant placement may play an important role in preventing ver-
tical bone loss, if the thickness of the buccal bone plate is 1 mm or
101 23
less. The systematic review by Lang et al analyzed six studies
where grafting materials were not used, 16 studies where bone sub-
stitutes were applied and in 12 studies the principle of guided bone
regeneration with bone substitutes was performed. In terms of sur-
vival rate, it seems that grafting or not grafting, the buccal void does
not affect implant survival; however, there is a lack of well‐con-
ducted randomized controlled trials assessing success rates and, in
particular, esthetic outcomes comparing grafting vs no grafting the
buccal void after immediate implant placement.23 Only one retro-
spective study compared success rates and hard and peri‐implant
soft‐tissue responses between placement and no placement of five
different types of graft. The implant survival rate was 100%
32 months after implant placement with no differences between
grafted and nongrafted groups. In terms of clinical and radiographic
examination, the types of graft placed in horizontal gaps had no
additional benefit in promoting better clinical outcomes given that a
thick gingival biotype was present.102 Thus, few preclinical models
and no prospective trials support the use of bone grafts on the buc-
cal gap after immediate implant placement. However, it can be sug-
gested that with a thin gingival biotype and narrow buccal bone
crest, the use of a graft can be recommended, in particular a slowly
resorbed biomaterial.
3.2.4 | Connective tissue graft
Buccal soft‐tissue recession has been commonly correlated with
labial implant positioning26 and thin gingival biotype.85 Therefore,
the use of connective tissue grafts as an envelope technique has
45
been proposed in order to prevent soft‐tissue recession. An experi-
mental study in dogs assessed the effect of connective tissue grafts
in conjunction with implant installation in fresh extraction sockets. In
the test group, implants were installed in fresh extraction sockets of
mandibular premolars and before suturing a connective tissue graft
ET AL.
F I G U R E 2 Three‐month buccolingual
section after immediate implant placement
with flap elevation (left) and flapless
surgery (right). Note the location of the
buccal bone plate on the right side of each
implant
was anchored to the buccal flap as an envelope technique. In the
control group, no connective tissue graft was applied. Four months
after implant surgery, the mean vertical buccal bone loss was
1.6 mm in the test group and 2.1 mm in the control. The difference
was not statistically significant. The coronal aspect of the peri‐
implant soft tissue was wider and located more coronally on the test
compared with the control sites. The difference was not statistically
significant, although it could be clinically relevant as the peri‐implant
mucosa was significantly thicker and more coronally positioned.
Thus, it seems that a connective tissue graft may not be so impor-
tant in terms of hard‐tissue alterations but in soft‐tissue outcomes.34
A systematic review assessed immediately placed single‐tooth
implants in the esthetic zone. The 1‐year survival rate was 97.1%.
The mean marginal bone loss was 0.81 ± 0.48 mm, the mean loss of
interproximal peri‐implant mucosa was 0.38 ± 0.23 mm and the
mean loss of peri‐implant midfacial mucosa was 0.54 ± 0.39 mm.36
There are very few studies assessing the effect of soft‐tissue grafting
in type 1 implant placement. A parallel randomized clinical trial ana-
lyzed clinical outcomes of immediate implants and immediate loading
with or without soft‐tissue grafting with the tunnel technique in the
labial area. Both groups received deproteinized bovine bone mineral.
Patients were observed over a 2‐year follow‐up. At the 2‐year exam-
ination, all 47 implants were successfully integrated with healthy
peri‐implant soft tissues. The results showed a soft‐tissue remodeling
of 10% reduction in thickness and 18% reduction in height in the
nongrafted group, whereas in the grafted group there was a gain of
35% in thickness and a reduction of 11% in height. The pink esthetic
score was 8 for the test group and 6.5 for the control group. Thus,
this study shows that the use of soft‐tissue grafting may improve
facial soft‐tissue stability and esthetic outcomes.103 Bianchi and San-
filippo,45 in a randomized clinical trial, compared soft‐tissue out-
comes around single immediate implants with or without a
connective tissue graft. The 9‐year cumulative survival rate was
100% for both test and control groups. Comparative statistical analy-
sis of soft‐ and hard‐tissue peri‐implant parameters demonstrated
better results in the test group than in the control group during
BLANCO ET AL.
every single 3‐year analysis and especially in the last observation
interval. The test group also showed very good results in terms of
esthetic parameters, which estimated the keratinized mucosa width,
the alignment of crown emergence profile and the patient's satisfac-
tion. However, 20% of cases in the control group were considered
unsuccessful. In longer follow‐ups (3‐9 years), mucosal recession of
>1 mm was observed in some patients; nevertheless, the position of
the soft tissue was generally stable when the connective tissue graft
was placed.45 Thus, connective tissue grafting may provide stable
peri‐implant soft tissues in the long term and with good esthetic out-
comes, mainly on those cases with a thin gingival biotype.
The role of the width of keratinized mucosa has not been tested
in preclinical and clinical studies of immediate implant placement.
Moreover, it seems that a band of at least 2 mm keratinized mucosa
may provide improved peri‐implant soft‐tissue health in the long
term. 104-107
However, in many instances, clinicians face cases of
tooth extraction and immediate implant placement with a minimum
or lack of keratinized mucosa. The use of connective tissue grafts at
the time of the surgery may increase the band of keratinized
mucosa. Another treatment option is to place a cover screw or a
narrow healing abutment after immediate implant placement and
wait for spontaneous gingival regeneration, similar to what happens
when a tooth is decapitated under the gingival margin.108 The
implant will probably submerge spontaneously, and at the second‐
stage surgery with a lingually placed incision, an increase in the buc-
cal keratinized mucosa can be achieved.
3.2.5 | Immediate loading/immediate
provisionalization
Some authors have suggested that certain load may increase the
amount of mineralized bone at the bone‐to‐implant interface and in
109,110
the peri‐implant bone area. Immediate implant loading may
stimulate bone formation and thus may influence early stages of
111,112
osseointegration. Moreover, immediately loaded implants pre-
sent with similar survival rates to implants loaded in a delayed proto-
113
col. According to the Fourth ITI Consensus Report, immediate
loading is defined as a provisional prosthesis connected to the
implant during the first week of healing; early loading 1‐8 weeks of
healing and conventional loading after 2 months.114
Two experimental studies have shown that immediate loading
per se does not affect osseointegration of immediate implants in
comparison with a delayed or no loading protocol.27,115 Moreover, in
terms of buccal bone crest resorption, immediate loading does not
have an impact on hard‐tissue changes after 3 months of heal-
27,115,116
ing. Thus, if primary stability is achieved, immediate loading
can be performed, but hard‐tissue changes on the buccal plate will
still be expected (Figures 3 and 4). A systematic review assessed
two immediate implant protocols in the esthetic region: single
implant restoration/loading in extraction sockets (the bimodal
approach) compared with the same in healed sites. Ten studies
showed that immediate single implant restoration/loading in extrac-
tion sockets in the esthetic zone was associated with significantly
| 161
higher risk of implant failure (risk ratio of 3.62, 95% CI 1.15‐11.45,
P = .03). However, the bimodal approach showed favorable marginal
bone changes after 1 year.40 In a recent systematic review,23 2086
immediate implants were conventionally loaded and 822 were imme-
diately loaded. The estimated annual failure rate of the conventional
loading group was lower than that of the immediate loading group
(0.75% vs 0.89%), but without statistically significant differences.
Immediately loaded and conventionally loaded implants showed
implant survival rates of 98.2% and 98.5%, respectively after 2 years.
However, it must be stressed that in most of the studies the occlusal
scheme provided to the provisional restorations was without con-
tacts. Therefore, it is not surprising to note that the differences in
survival rates between the two groups with varying loading proto-
cols were not significant.
In terms of radiographic hard‐tissue changes, this systematic
review showed that at 1 year the loss was <1 mm (range: gain 1 mm‐
loss 0.98 mm) and longer term evaluations demonstrated that after
the first functioning year bone levels became stable.23 In a prospective
study, marginal bone changes over 12 months were assessed on
immediate implant placement and immediate restorations. In the 3‐12‐
month interval there was a continuous marginal bone loss from
0.51 ± 0.24 to 0.95 ± 0.35 mm at the mesial site and 0.52 ± 0.46 mm
to 0.79 ± 0.39 mm at the distal site. Half the bone loss measured in
the first year occurred in the first 3 months.35 Moreover, a systematic
review stressed that delayed provisionalization of immediate implants
increased the odds ratio by 20 on marginal peri‐implant bone level
change >0.5 mm. Thus, it seems that the use of an immediate provi-
sional restoration may obtain better peri‐implant bone levels than
immediate implants without a provisional restoration. This may be
more critical when peri‐implant soft tissues are assessed.36 In fact, the
systematic review by Lang et al23 reported data on three studies that
analyzed soft‐tissue changes following immediate implant placement
with immediate provisional restoration. In those studies, most of the
soft‐tissue changes occurred within the first 3 months.35,53,54 Mesial
and distal papillae decreased 0.41 ± 0.32 mm and 0.34 ± 0.36 mm,
respectively. The recession of buccal peri‐implant mucosa was
0.43 ± 0.38 mm when compared with the presurgical level. Soft tis-
sues became stable after 6 months, as at the end of the first year
0.49 ± 0.31 mm shrinkage at the mesial papilla, 0.36 ± 0.33 mm at
the distal and 0.51 ± 0.38 mm buccal mucosa margin had occurred
from baseline. If the obtained results comparing immediate implant
placement and provisional restoration vs a delayed restoration are
analyzed, they indicate that at 3 months mean papilla shrinkage was
about twice as high in the delayed restoration group as it was in the
immediate provisional group.35 However, in the following 9 months,
papillae in the delayed restoration sites showed a tendency to fill the
proximal spaces and the differences between the groups became
smaller. Nevertheless, when changes in the midbuccal mucosa are ana-
lyzed, the apical displacement of the buccal mucosal level was around
two to three times higher in the delayed restoration group compared
with the immediate provisional at 1 year of follow‐up. It was con-
cluded that this difference favored immediate restoration of immedi-
ate implant placement.35
162 | BLANCO ET AL.

F I G U R E 3 Immediate implant
placement with and without immediate
loading

F I G U R E 4 Immediate implant placement with or without immediate loading. Buccolingual sections representing specimens of implant
groups at premolar 3 and 4 regions after 3 mo of healing. IL, immediate loading; IP, immediate placement; NL, no loading

Although the use of a platform‐switching technique, where a
wider diameter implant is restored with a narrow diameter abutment,
was studied to minimize hard‐tissue changes, this concept seems to
be controversial and needs further investigation.58 A randomized
clinical trial studied radiographic bone changes after the placement
of immediate implants with immediate restorations.117 One group
received 34 implants with an external hexagon junction with the
matched abutment and the other 30 implants had platform‐switching
abutments. After 24 months, a cumulative survival rate of 100% was
reported for all implants. The platform‐switching group showed a
mean bone loss of 0.78 ± 0.49 mm and the external hexagon group
showed a mean bone loss of 0.73 ± 0.52 mm (no statistically signifi-
cant difference between groups). A prospective study evaluated the
survival rates at 12 months of an implant with a platform‐switching
BLANCO ET AL.
design placed in the anterior and premolar areas of the maxilla and
immediately restored with single crowns. Sixty‐one implants were
placed into fresh extraction sites in 25 men and 25 women. One
implant failed and one was lost to follow‐up. The 1‐year mean bone
loss measured on the mesial sites was 0.08 mm (SD 0.53 mm) and
0.09 mm (SD 0.65 mm) at the distal sites.118 The small bony changes
were in accordance with those reported by Canullo et al,58 who
showed that after about 2 years of loading, the platform‐switching
group experienced bone loss of 0.25 mm mesially and 0.36 mm dis-
tally; the bone loss was more significant in the platform‐matching
group, reaching 1.13 and 1.25 mm on mesial and distal surfaces,
respectively.
It has been reported that multiple abutment disconnections and
reconnections following implant placement may compromise the peri‐
implant mucosal seal and may lead to increased marginal bone
119,120
loss. The additional marginal bone resorption observed follow-
ing abutment manipulation may be the result of tissue reactions initi-
ated to establish a proper “biological width” of the mucosal‐implant
barrier. However, a randomized controlled clinical trial showed that
the mean marginal bone loss at 6 months was 0.13 mm for implants
placed in healed sites and connected the day of surgery to a definitive
abutment; the bone loss for the group where the abutment was con-
nected and disconnected two times was 0.28 mm. These results were
not significant and there were no significant differences regarding
changes in peri‐implant mucosal dimensions between the two groups.
Thus, at healed sites, it seems that on a short‐term basis, there is no
difference between placing a definitive abutment at the time of
implant surgery or performing the standard protocol of implant‐level
impressions and connection/disconnection of the abutments after the
osseointegration process.121 Regarding extraction sockets and imme-
diate implants, a 3‐year randomized controlled trial was published by
Canullo et al.122 The aim was to evaluate the influence of restoration
on marginal bone loss using immediately definitive abutments or pro-
visional abutments later replaced by definitive abutments. Twenty‐five
patients with 25 hopeless maxillary premolars participated. At the 3‐
year follow‐up a survival rate of 100% in both groups was reported. In
the provisional abutment group, peri‐implant bone resorption was
0.36 mm at 3 months, 0.43 mm at 18 months and 0.55 mm at
3 years. In the definitive abutment group, peri‐implant bone resorp-
tion was 0.35 mm, 0.33 mm and 0.34 mm at the same time intervals.
Lower bone loss was significant in the group with definitive abutments
122
at 12 months (0.1 mm) and 3 years (0.2 mm). This trial suggested
that the use of definitive abutments after immediate implant place-
ment might be a potential factor to minimize peri‐implant crestal bone
resorption, but more clinical trials should be performed to better
investigate this hypothesis.
In the context of provisional restorations and definitive abut-
ments, studies have not addressed the length of the abutments. In
multiple teeth extraction and implant placement, implant manufac-
turers provide abutments for screw‐retained restorations. These
abutments have different lengths and diameters, ranging from 1 to
4.5 mm in length and 3.5 to 6 in diameter. The concept of biological
width plays an important role in soft‐ and hard‐tissue changes at
| 163
implant sites. Studies in the late 1990s have clearly shown that the
closer the connection of the prosthesis with the implant heads, the
more bone loss can be expected in order to establish the biological
width.123-126 Those studies were performed on healed ridges. A dif-
ferent scenario is a postextraction site. The coronal part of the
extraction socket is not usually flat, with more coronal level of the
interproximal bone than at the buccal aspect. Thus, if recommenda-
tions of placing immediate implants 1 mm below the buccal bone
crest is taken, longer abutments must be connected. For example, a
1 mm abutment may be almost at the level of the buccal bone crest,
but probably subcrestal at the proximal sites. One can expect that
hard‐tissue remodeling will eventually induce bone loss in order to
establish a proper biological width, as the connective tissue length is
always apical to the abutment/restoration connection.123-126 Longer
abutments are recommended in postextraction immediate implants
in order to prevent further bone loss. However, although biologically
plausible, it has not been tested experimentally or clinically.
3.2.6 | Antibiotics
A Cochrane systematic review suggested that the benefits of antibi-
otic prophylaxis in pristine sites remain unclear and it may not be
needed.127 However, a recent review analyzed 33 studies where
antibiotics were prescribed in immediate implant placement in
healthy sites. Four studies involved a preoperative single dose of
antibiotic prophylaxis, whereas postoperative antibiotic use of 5‐
7 days was reported in 15 studies. Another 14 studies provided
information about both preoperative single dose and postsurgical (5‐
7 days) antibiotic prescription. The results showed that the esti-
mated annual failure rate for the preoperative antibiotic regimen
group was 1.87%, and for the postoperative antibiotic regimen
group, and pre‐postoperative antibiotic regimen group were lower
(0.51% and 0.75%, respectively).23 Thus, available evidence suggests
that not only the prescription of an effective antibiotic, but also the
duration of usage may contribute to higher implant survival rates. In
another review it was not possible to analyze the role of antibiotics
and mouth rinses when placing implants in healthy subjects, due to
the use of different types and schedules in antibiotic prescription.36
4 | CONCLUSIONS AND CLINICAL
RECOMMENDATIONS
As in most medical treatments, case selection is crucial for outcomes
success. Also, for implant treatment, at the patient level, primary dis-
eases of soft and hard tissues must be under control and systemic risk
factors such as smoking or poor controlled diabetes must be
addressed. It is clear that the decision to perform an immediate
implant must be considered with the patient, weighing up potential
benefits and drawbacks. If an immediate implant placement is chosen,
proper planning of the case is mandatory. Nowadays, cone beam com-
puted tomography scans help to make the decision of whether to per-
form an immediate implant placement or use a delayed approach.
164 | BLANCO
Moreover, if the plan is an immediate implant, the scan can provide
information to guide the surgery. If in the scan it is clear that there is
no bony dehiscences or fenestrations, an immediate implant proce-
dure can be performed. Following an atraumatic tooth extraction
approach, a thorough cleaning of the socket with curettes and saline
or chlorhexidine is recommended. Good inspection of the socket walls
to check for the lack of bone defects is mandatory. Soft‐tissue length
can be measured, in particular on the buccal aspect, in order to place
the implant with the soft‐tissue margin as a reference instead of the
bone. The length of the alveolus should also be measured in order to
select the adequate implant length for the case. The implant should be
placed towards the palatal wall and around 1 mm subcrestal to the
buccal bone plate. However, it is important that the implant placement
is prosthetically guided, thus, on some occasions the implant cannot
go so palatal. Usually, the resultant buccal defect gap is filled with a
slow resorbed bone graft. However, in cases with thick buccal bone
(>1.5 mm), a thick biotype and a gap <1.5 mm, one can decide not to
place the graft, as its benefit will probably be minimal. Once the
implant is placed, a connective tissue graft can be tunnelized on the
buccal aspect, in particular in thin gingival biotypes and highly esthetic
demands. If primary stability is achieved, a provisional restoration can
be placed after implant‐level impression for a single tooth or with
abutment‐level impression for partial and full arch implant restora-
tions. The head of the abutment should be at least 1 mm coronal to
the buccal bone crest, taking into account that 0.5‐1 mm soft‐tissue
recession can occur after long‐term healing. Those provisional restora-
tions can also be chairside manufactured. Strong occlusal contacts
should be avoided and, whenever possible, no contacts. The abut-
ments and provisional restorations should also respect the proximal
hard and soft tissues. Thus, the use of the switching‐platform concept
with narrow abutments and prosthesis may be advisable. Antibiotic
prophylaxis can be recommended and, in particular, postoperatively
for a 5‐7 day course.
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How to cite this article: Blanco J, Carral C, Argibay O,
Liñares A. Implant placement in fresh extraction sockets.
Periodontol 2000. 2019;79:151‐167. https://doi.org/10.1111/
prd.12253