DOI: 10.1111/prd.
12319
REVIEW ARTICLE
Advances in implant therapy in North America: Improved
outcomes and application in the compromised dentition
Hanae Saito1 | Mary Beth Aichelmann‐Reidy1 | Thomas W. Oates2
1
Division of Periodontics, Department of Advanced Oral Sciences & Therapeutics, University of Maryland School of Dentistry, Baltimore, Maryland, USA
2
Department of Advanced Oral Sciences & Therapeutics, University of Maryland School of Dentistry, Baltimore, Maryland, USA
Correspondence
Hanae Saito, Division of Periodontics, Department of Advanced Oral Sciences & Therapeutics, University of Maryland School of Dentistry, 650 West Baltimore
Street, Room 4201, Baltimore, MD 21201, USA.
Email: hsaito@umaryland.edu
1 |  I NTRO D U C TI O N
Through advances in their application and technology, the benefits
of dental implant therapy continue to grow for our patients. These
advances support our understanding of the management of the im‐
plant‐soft tissue interface, with site‐specific implications ranging
from marginal tissue management and esthetics to immediate place‐
ment and restoration, and extend to patient‐level implications of
systemic conditions on oral implant therapy.
The expansion of implant therapy has placed an increased em‐
phasis on patient‐centered outcomes. Improvements in both esthet‐
ics and long‐term maintenance have been guided by study of the
marginal peri‐implant tissues, leading to innovations in implant de‐
sign along the implant‐abutment interface. Patient expectations for
simple and realistic time intervals for treatment have promoted the
use of immediate implant placement and restoration.
Based on our understanding of the pathologic underpinnings of
numerous medical conditions, our profession has been conservative
in extrapolating the use of implant care for individuals with chronic
diseases which are likely to compromise outcomes. However, the ex‐
pansion of implant therapy in practice now includes offering implant
options for patients with medical conditions who would have oth‐
erwise been denied the benefits of implant therapy. One condition
in particular, diabetes mellitus, may have a major impact on dental
implant treatment outcomes. Numerous studies with patients with
diabetes have promoted broader inclusion of this patient population
and supported the development of evidence‐based treatment con‐
siderations for patients with other systemic conditions. These stud‐
ies have supported broader application and greater benefits of the
use of implant therapy to a larger patient population.
This paper offers a representative, but not comprehensive, re‐
view of the contributions of US and North American clinicians to
the global scientific dialogue that has guided the development of
Periodontology 2000. 2020;82:225–237. wileyonlinelibrary.com/journal/prd   © 2019 John Wiley & Sons A/S. |  225
endosseous dental implant therapy. It focuses on implant design in
guiding the osseous‐mucosal interface and its potential impact on
esthetic outcomes, the movement towards shortened treatment
time and greater use of immediate implant placement and resto‐
ration, and the use of evidence‐based care to support a broader in‐
clusion of medically compromised patients.
2 | E M E RG E N C E O F E S TH E TI C S I N
I M PL A NT TH E R A PY
Given the challenges in optimizing esthetic results for tooth replace‐
ment with implants, there has been increased interest in managing
the implant interface of both hard and soft tissues. This has led to a
greater emphasis on implant design and surface physical character‐
istics, both at the micro‐ and macroscopic levels required to achieve
positive functional and esthetic outcomes. One specific challenge
that continues today is the successful long‐term management, mod‐
eling, and maintenance of peri‐implant mucosal tissue, including
papillae, in harmony with the soft tissues of the adjacent natural
dentition.1-4
The oral mucosa plays an important role as a biologic barrier
along the transmucosal aspect of the implant. Early studies fo‐
cused on understanding the relationship between the oral mucosa
and implant surface. 5,6 As the peri‐implant epithelium was found
to ultimately contact only the implant body apical to the implant‐
abutment interface, these studies defined the establishment of a
biologic width around dental implants. It was shown that this pro‐
cess was guided by both the implant‐restoration interface and im‐
plant surface roughness. Therefore, based on implant positioning,
these factors could influence crestal bone remodeling in estab‐
lishing an interface with both connective tissue and junctional ep‐
ithelium. Thus, these early studies demonstrated the potential for
Published by John Wiley & Sons Ltd
 |
226       SAITO et al.
implant design characteristics to influence the soft and hard tissue
responses.
One of the more striking early differences in implant design
was the use of a one‐piece, nonsubmerged implant, which is a solid
implant body that includes a transmucosal component, and a two‐
piece, submerged implant with a separately attached transmucosal
component.7,8 It is the two‐piece implant that requires a connection
between the two separate components, implant body and trans‐
mucosal abutment, which creates what has been termed the “mi‐
9
crogap” (Figure 1).
Interestingly, the one‐piece implants had a designed area as part
of the implant body that transitioned from the implant's osseous in‐
terface to that of the mucosal interface. The osseous interface was
a roughened surface similar to those ubiquitous today, while the mu‐
cosal interface had a smoother surface, giving a greater likelihood of
maintaining effective oral hygiene. Studies of the one‐piece implant
design clearly demonstrated that the border between rough and
smooth implant surfaces relative to the osseous crest have clinically
significant influences on peri‐implant crestal bone levels and soft
and hard tissue dimensions (biologic width).10-12 These studies were
instrumental in (a) building our understanding of the interaction of
osseous tissues with the roughened surfaces, and (b) demonstrating
the potential for implant design to influence the hard tissues along
the osseous crest. The supracrestal positioning of the rough‐smooth
border at the osseous crest or supracrestal location resulted in sig‐
nificantly less marginal bone resorption than when positioned api‐
12,13
cally to the osseous crest.
Similar to the influence of the apico‐coronal positioning of the
rough‐smooth border of one‐piece implants, the position of the
F I G U R E 1   Schematic diagram of a nonsubmerged (one‐piece)
dental implant on the left, and a submerged (two‐piece) implant on
the right. The one‐piece implant has its interface above the bone
level; the two‐piece implant has its interface at the original bone
crest level. After this interface is created at the bone crest, bone
resorption occurs mesial and distal (in the schematic) but actually
all around the implant, down to the first or second thread level. The
crown length (CL) to implant length (IL) is less in the nonsubmerged
(one-piece) design compared with the submerged (two-piece)
design. (Courtesy of Institut Straumann AG, Basel, Switzerland,
with permission) [Colour figure can be viewed at wileyonlinelibrary.
com]
implant‐abutment interface for the two‐piece implant had a direct
impact on the osseous crestal remodeling that occurred following
placement. In earlier implant‐abutment designs for the two‐piece
implants, there was a straight or flat profile from implant to abut‐
ment. It was found in these situations that the mucosal attachment
to the dental implant surface formed apically to the microgap, often
resulting in crestal bone remodeling.14 In fact, the criteria for implant
success recognized the inevitability of this type of crestal remodel‐
ing, and anticipated one millimeter of crestal bone loss within the
first year following placement. Although it was not quite clear as to
the cause, implant success was often dependent on marginal bone
level changes in the first year after implant placement of less than
1‐1.5 mm, with subsequent annual bone loss of less than 0.2 mm.15,16
The two‐piece implant design resulted in the positioning of the
implant microgap in close proximity to the soft tissue interface. The
introduction of the microgap with its microbial contamination was
subsequently shown to be a contributor to peri‐implant mucosal
inflammation.17 This was most evident as a broader area of muco‐
sal inflammation as the implant‐abutment interface was positioned
further apically into the mucosal tissues and closer to the osseous
crest, and especially as the abutment became exposed to the oral
environment.17
Several studies indicated that bacteria were present on these
interfaces, associated with inflammation, and that the location of
the interface in an apico‐coronal direction was correlated with the
degree of marginal bone loss17-19 (Figure 2A,B). Histologic studies
demonstrated that the apical extension of the junctional epithe‐
lium was always located below (apical to) the interface or microgap
with neutrophils and mononuclear cells (Figure 2C).10 These studies
provided further evidence that the mucosal‐implant interface was
significantly influenced by the presence/absence of a microgap be‐
tween the implant and the abutment, and by the location of this mi‐
crogap in relation to the crest of the bone as part of the individual
implant design characteristics.11
The pathophysiologic consequences of the implant‐abutment
interface position have important implications, since esthetic de‐
mands encourage the placement of implants in a more apical posi‐
tion. Importantly, these studies highlighted the role of the location
of the interface relative to the alveolar crest in contributing to the
magnitude of the peri‐implant bone loss.17,20 The importance of
these implant design characteristics become increasingly important
toward accommodating the peri‐implant soft tissues and potential
esthetic sequelae such as loss of papillary tissue between the im‐
plant and the adjacent tooth, or between two implants.14,21
The understanding of the microgap in establishing the crestal
bone position has been used to develop more recent design ap‐
proaches to the implant‐restorative interface. This approach, with
nonmatched components, appears to capture some of the advances
gained from both the one‐piece and two‐piece designs. Conventional
matched diameter, two‐piece implants provide a flat profile between
the two components with only a thin gap, or junction, between these
components. The nonmatched diameter (“platform switching”) im‐
plant shifts the perimeter of the implant‐abutment junction inward
SAITO et al. |
      227

F I G U R E 2   Implant design and

(A)
placement, histomorphometric study area,
and histology. (A) At the time of initial
surgery, implants were positioned so
that the implant‐abutment interface was
either supracrestal, crestal, or subcrestal
to the alveolar bone, ie, 1 mm coronal to,
at, or 1 mm apical to the alveolar bone
crest, respectively; 3 mo later, abutments
(outlined by a dashed line) were
connected to implants. After 3 additional
months, specimens were processed
for histomorphometric analyses. (B) (B)
Sequential histologic fields of apico‐
coronal peri‐implant soft tissue were
digitally captured. (C) Photomicrographs
of representative soft tissues immediately
adjacent to the implant‐abutment
interface. Although neutrophils are
abundant in the specimen with crestal or
subcrestal placement, these cells were
infrequent in the supracrestal specimen.
A, abutment; AB, alveolar bone; BC,
bone crest; CT, connective tissue; GE,
gingival epithelium; IAI, implant‐abutment (C)
interface; R, rough portion of implant
(SLA® surface); S, smooth‐machined collar
of implant

F I G U R E 3   Two examples illustrating (A)

new bone formation onto the bevel of (B)
the implant: (A) vertical (coronal) bone
growth occurred after implant placement;
(B) another example revealing new bone
growth coronally and on the bevel of the
implant [Colour figure can be viewed at
wileyonlinelibrary.com]

towards the center of the implant body by using a smaller‐diameter
abutment on a larger‐diameter implant collar to reduce the amount
of crestal bone remodeling. 22 As the abutment diameter is decreased
relative to the implant diameter, a horizontal dimension is created to
accommodate soft tissue attachment to the implant system with less
osseous crest remodeling. Thus, this design shifts the microgap and
its associated inflammatory cell infiltrate further from the osseous
tissues by adding a horizontal as well as a vertical dimension to the
mucosal interface.19,23,24 It has been shown that when a nonmatched
diameter implant‐abutment connection was placed at the crestal
bone level, bone loss was significantly less than that reported for
bone level implant connections with matching implant‐abutment
diameters, but more than that observed for one‐piece implant de‐
signs25,26 (Figure 3).
 |
228       SAITO et al.
The nonmatched design continues as a commonly used ap‐
proach. Nonetheless, one must also recognize the importance
of initial soft tissue thickness for the formation of biologic width
around implants. It has been shown in animal and human clin‐
ical studies that thin vertical tissue thickness is associated with
bone loss during establishment of peri‐implant mucosa when the
implant is placed at the level of osseous crest. 27,28 The effect of
the nonmatched diameter implant on a thin soft tissue biotype
remains to be determined. 28-30 Even with thicker peri‐implant mu‐
cosal tissue, a microgap‐related inflammatory response is evident,
leading to greater crestal bone remodeling than with supracrestal
implant placement. 31
Looking forward, novel abutment and supracrestal component‐
related features will be used to better manage peri‐implant and
peri‐abutment soft tissue attachments.32,33 Implant abutment and
supracrestal component surface characteristics have been shown
to affect the epithelium, fibroblast, and osteoblast cell behavior.34
Studies have demonstrated the potential for supracrestal connective
tissue attachment on a textured implant abutment surface.33,34 In
vitro studies have demonstrated that different surface development
techniques (such as laser‐treated titanium, acid‐etched titanium‐zir‐
conia alloy, and dual thermal acid‐etched surface titanium) produce
rough surfaces offering enhanced connective tissue cell prolifera‐
tion and cell adhesion. Histologic analyses from animal and human
studies show that such treated surfaces have the potential to con‐
trol the distribution and position of collagen fibers to the surface of
the implant/abutment with the junctional epithelium more coronal
relative to the implant shoulder, altering the zone of the mucosal‐
implant interface, and resulting in less osseous crestal remodeling
than with untreated abutments. There remains the opportunity for
innovations in implant designs to leverage our knowledge in the area
of the soft‐tissue implant interface to produce greater patient‐fo‐
cused success.35
3 |  I M M E D I ATE I M PL A NT TH E R A PY
As patient expectations continued to challenge traditional implant
treatment protocols, the exploration of immediate implant place‐
ment in extraction sites was introduced and promoted to reduce
surgical interventions and the time necessary to reach a func‐
tional implant restoration. The application of these approaches
coincided with the increased use of roughened implant surfaces
that enhanced initial implant stability and early implant survival.
Early successes in these approaches were promoted by clinicians
in North America, who explored the necessity for bone grafts and
introduction of application barrier membranes to enhance clot
stability around the dental implant which did not fully engage the
bony socket walls. 36-40 Challenging the conventions established for
delayed implant placement, the placement of implants in sites with‐
out complete bony housing or absence of infection at the time of
extraction was a hallmark of several early case series with reported
successes. 36-40
Overall, the early focus for this technique's success was defined
by implant survival. When introduced for improved and immediate
function, while successes were reported, a delayed approach re‐
mained the treatment of choice, especially when multiple unit fixed
provisional restorations were planned.41 As the early exploration
of immediate implant placement progressed in North America, the
focus on function and esthetics changed the determinants of defin‐
ing success. It was recognized that modifications made to the place‐
ment environment could control potential shortcomings for the final
esthetics of the outcome as well as improving immediate implant
placement survival.
The criteria for early success were proposed by Garber et al42 as a
means of preserving bone and soft tissue contour while maintaining
function. They conceptualized and reinforced the necessary param‐
eters for success. These parameters included an interproximal bone
height of no more than 4‐5 mm from the contact point, an intact
labial bony housing with bone crest of no more than 3 mm from the
future restorative gingival margin, and atraumatic tooth extraction
where there was no loss of periodontal support.43 This group rec‐
ommended using a wide‐diameter, tapered, roughened surface im‐
plant and an incisionless approach, thus eliminating the necessity
for membrane placement which could disrupt the periosteum and
gingival tissue blood supply. With this approach, placement of a final
esthetic restoration would be possible in 6‐8 weeks following tooth
extraction. Using this protocol, these early investigators found that
only one of 23 anterior sites failed to integrate. Around the same
time, another group of US investigators also established a proto‐
col for the placement and provisionalization of immediate implants
in the esthetic zone: Kan et al44 placed 35 threaded, hydroxyapa‐
tite‐coated implants after tooth removal, finalizing the restorations
after 6 months, and reported acceptable clinical results and patient
satisfaction, despite noting statistically significant changes in mar‐
ginal bone and gingival level between pretreatment and 12‐month
follow‐up. Additionally, the importance and impact of initial implant
stability in extraction sites as a determinant for loading and provi‐
sionalization of immediate implants has also been assessed by North
American clinicians, which has modified the indications for immedi‐
ate implant placement in practice.
4 | R E D E FI N I N G PR I M A RY S TA B I LIT Y
Primary stability and its impact on implant integration was charac‐
terized in a prospective cohort study that longitudinally compared
resonance frequency values of implants placed in edentulous sites
of native bone vs those for immediate implants placed in extraction
sockets of anterior and premolar areas. 45 In this prospective clinical
trial, the baseline implant stability quotient values (stability) were
not statistically different for the group where implants were placed
in native bone vs implants placed in extraction sites.45 With immedi‐
ate implant placement, a significant decrease in stability occurred
over the first 4‐8 weeks, approaching 15% of the initial primary
stability at the time of implant placement. Hence, it was noted that
SAITO et al.
considerable bone remodeling can occur in the first months follow‐
ing placement into extraction sites. However, it should be noted that
all of these immediate implant treatment outcomes were success‐
ful. Importantly, the study also found that all immediate implants
demonstrated a similar decrease in stability, but for those implants
starting with a higher initial stability, the drop in stability did not
result in as low a level of stability as those starting from a lower
initial stability.45 Interestingly, self‐tapping, tapered implants did not
offer superior stability or advantage in extraction sites in this report,
which was contrary to recommendations of others for the enhanced
stability of immediate placement.
A retrospective case series reported success rates of 95.5%, even
with low‐insertion‐torque values of 25 Newton centimeters or less
for immediately restored single‐tooth implants placed into fresh ex‐
traction sockets and restored with acrylic resin provisional crowns.46
Nonetheless, in general, fewer complications have been reported
when immediate implants are placed with higher insertion torque
values. In a retrospective case series of implants placed at Loma
Linda University, tapered implants placed in immediate extraction
sites had only a 1.1% incidence of rotation instability as opposed
to 20.5% of those with a nontapered morphology.47 Furthermore,
it was noted that preparation within the extraction socket with an
implant drill discrepancy of less than or equal to 0.5 mm reduced
the incidence of rotational implant instability and allowed for subse‐
quent immediate provisionalization.
Through the efforts of these clinicians, determinants for suc‐
cess and recognition of the impact of patient phenotype, soft tissue
and bony profile, and residual defect morphology, were established
for the development of a successful immediate implant placement
48
protocol. More recently, through collaboration with multiple USA‐
based authors, keys for success in the esthetic zone are now outlined
to address concerns of inadequate dimension and phenotype.49,50
The emphasis for success is now on establishing, through augmenta‐
tion, the essential attributes of the implant site, despite the patient's
F I G U R E 4   Occlusal view of the implant position relative
to the buccal plate. The buccal gap was noted (green arrow)
between implant body and inner aspect of the socket. Courtesy
of Quintessence Dental Technology 2019 [Colour figure can be
viewed at wileyonlinelibrary.com]
|
      229
original phenotype, along with consideration of patient satisfaction
and esthetics.
5 | PR E S E N C E O F TH E “ G A P ” B E T W E E N
TH E I M PL A NT A N D A LV EO L A R H O U S I N G
A N D B O N E R E M O D E LI N G A RO U N D
I M M E D I ATE I M PL A NT S
With respect to the alveolar housing, early exploration of this im‐
mediate placement technique led to the recognition that the “gap”
or discrepancy between the extraction socket morphology and the
implant fixture will fill with bone (Figure 4). At sites with horizon‐
tal defects of 2 mm or less, bone regeneration is expected when
roughened surface implants are used.51 When horizontal defects
exceed 2 mm or there are missing socket walls, bone augmentation
has attained success rates comparable with delayed implant place‐
ment.48,51 Nevertheless, success has also been reported with sites
exceeding the recommended 2 mm defect gap in molar extraction
sites, and success has even been accomplished without bone graft‐
ing.52 Moreover, a success rate as high as 99.5% has been reported
where less than optimal bone quality exists, as in maxillary molar
extraction sites.53 Certainly, the evolution of the placement of the
immediate implant challenges the traditional dogma of higher suc‐
cess rates for conventional delayed implant.
Notwithstanding documented success rates for immediate im‐
plant placement (implant survival) comparable with delayed place‐
ment, there are concerns about this approach from clinicians/
investigators based outside the USA regarding immediate implant
placement in the esthetic zone. It has become clear that the remod‐
eling of bone observed following tooth extraction is not eliminated
with immediate implant fixture placement. However, the dimen‐
sional bony changes and soft tissue changes after immediate implant
placement remain poorly characterized. In a review by Lee et al,54 a
dimensional reduction of buccal bone (0.5‐1 mm) could be expected
F I G U R E 5   After the implant placement, the buccal gap between
the implant and alveolar housing was filled with particulate
allograft prior to placement of provisional restoration. Courtesy
of Quintessence Dental Technology 2019 [Colour figure can be
viewed at wileyonlinelibrary.com]
 |
230       SAITO et al.
F I G U R E 6   Occlusal view of the ridge 2 years after immediate
implant/immediate provisional restorations. Note maintained
bucco‐lingual ridge width compared to contralateral tooth (#9)
[Colour figure can be viewed at wileyonlinelibrary.com]
within 1 year of immediate implant placement, and the buccal plate
thickness of the socket after extraction may predict the pattern
of the future buccal bone loss. In a recent randomized, controlled,
clinical trial comparing 12‐month follow‐up of immediate implant
placement and provisionalization with or without flap elevation,
postsurgical marginal recession of 0.22 ± 0.31 mm for the flapless
sites vs 0.42 ± 0.52 mm with flap elevation was noted when com‐
pared with presurgical levels.55 Comparable remodeling of the mu‐
cosa and buccal and interproximal bone for the two treatment arms
at 12 months was reported.
6 |   I M M E D I ATE I M PL A NT/I M M E D I ATE
PROV I S I O N A L R E S TO R ATI O N S
Tarnow et al,56 reporting on a cohort examined retrospectively,
found only limited facial‐palatal contour change in the esthetic
zone when using a flapless technique with graft placement and a
contoured healing abutment or provision restoration. This reported
methodology includes palatally biased implant placement to pre‐
vent formation of a facial bony dehiscence around the implant. The
authors in this report characterized minimal bone remodeling with
flapless placement, which allowed for increased dimension of facial
bone from fill of the implant to bone gap. Additionally, a net gain of
about 1 mm of soft tissue dimension was noted in grafted sites with
this approach. Analysis of grafted sites demonstrated increases in
vertical and horizontal dimensions of between 0.5 and 1.0 mm when
compared with sites without bone graft and no provisional restora‐
tion57 (Figures 5 and 6).
This clinical approach has been further validated by the cu‐
mulative success, reported by Gelb58 in a large practice‐based
case series, for which immediate implant placement with immedi‐
ate provisional restoration attained good reported esthetics and
high patient satisfaction. 58 In this case series, all patients treated
from 1988 to 2018 with implants and followed for a minimum of
5‐16 years were included. These included 8319 immediate implant
sites where 2493 were treated with immediate implant/immediate
provisional restorations, and 5826 were treated with immediate
TA B L E 1   Parameters for successful immediate implant
placement in the esthetic zone50
10 keys for immediate implant success in the esthetic zone
1. Esthetic risk assessment
2. Tomographic plan: cone‐beam computed tomography and re‐
storative‐driven treatment plan
3. Minimally traumatic tooth extraction, flapless with evaluation of
buccal plate
4. 3D implant placement in good available bone, both apically and
palatally along the palatal wall
5. Use of narrow diameter (3.3‐4.3 mm vs 4.5 mm or greater
implants)
6. Bone grafting of the buccal gap with a low substitution small
particle mineralized bone graft
7. Facial soft tissue grafting with palatal subepithelial connective
tissue graft placed in a buccal envelope under the buccal marginal
tissue and facial to the intact buccal plate
8. Immediate contour management of the emergence profile from
the implant
9. Once soft‐tissue esthetics are established with a provisional, a
custom impression coping technique should be used to duplicate
the transition zone, and transfer to the lab model
10. Final restoration with a screw‐retained crown
implant/no restoration. The author concluded that atraumatic ex‐
traction, immediate implant placement with a chair‐side tempo‐
rary restoration was achievable. Interestingly, 2361 sites had no
bone or barrier membrane placed. The author almost exclusively
used a flapless approach (99%) for the immediate implant/imme‐
diate provisional restoration group. The cumulative success rate
of the immediate implant/immediate provisional restoration group
was 95.1%, while the success rate of the immediate implant/no
restoration group was 94.5%. Patients and dentists were queried
as to outcome satisfaction for the procedure and final esthetics,
and responses from the immediate implant/no restoration group
compared favorably with the immediate implant/immediate pro‐
visional restoration group. Treatment with an immediate implant/
immediate provisional restoration did not lead to less favorable
or compromised treatment outcomes when compared to imme‐
diate implant placement alone, and these outcomes were main‐
tained following functional loading and provided high patient
satisfaction.
This large practice‐based report provides contradictory conclu‐
sions when compared with a recent randomized, multicenter, clinical
trial conducted outside the USA.59 In this clinical trial, wound failure
(defined as wound dehiscence, suppuration, and swelling in the first
6 weeks) was five times more frequent at immediately placed im‐
plant sites vs delayed, with more postoperative complaints. In this
trial, immediate implants more often had inadequate pink soft tissue
aesthetic clinical scores around the cervical portion of the implant
and greater probing depths. However, there were no patient‐re‐
ported differences in outcomes or patient satisfaction between the
two approaches in this trial. Patient satisfaction was greater than
SAITO et al.
(A) 1 wk
(B) 4 wk
F I G U R E 7   Representative example of implant soft tissue
healing (A) 1 wk and (B) 4 wk following surgical placement. This
55‐y‐old male patient had an HbA1c of 10.1% at the time of implant
surgery. The implant was used to support a removable partial
prosthesis [Colour figure can be viewed at wileyonlinelibrary.com]
85% for both immediate and delayed implant placement for anterior
single‐rooted teeth.
Likewise, in a recent systematic review comparing the suc‐
cess and peri‐implant outcomes of immediate and delayed implant
placement, the authors recommended caution when placing imme‐
diate implants since there was a significantly greater survival rate
of delayed implants (98.38%) compared with immediate implants
(95.21%).60 However, no significant differences were found regard‐
ing marginal bone loss, implant stability values after healing, and
pocket probing depth, when comparing the two groups. In summary,
despite successes, some skepticism and caution prevails regarding
immediate implant placement from investigators/clinicians outside
the USA.
As the focus has shifted to the importance of the evaluation of
patient‐centered outcomes, the validity of immediate implant place‐
ment as an acceptable treatment option remains. Two short‐term
studies have evaluated esthetic outcomes in facial marginal tissues
|
      231
following immediate implant placement in comparison with place‐
ment following ridge preservation or with early (partially healed site)
placement.61,62 Optimal esthetic and clinical outcomes were found
in both studies irrespective of the placement protocols. Considered
together, these studies challenge some of the esthetic concerns
with immediate placement. More recently, a USA‐based private
practice network (nine board‐certified periodontists) reported their
collective assessment of immediate implants with simultaneous res‐
toration in the anterior maxilla between the first premolars.63 The
mean follow‐up time was 15.4 months. Out of a visual analog scale
of 10, an average score of 9.3 was reported by the surgeons, and
9.5 from the patients for esthetic results and overall implant satis‐
faction. No reported change in facial gingival margin stability was
reported for 76% of the implants, while 9% demonstrated coronal
migration of the facial gingival margin, and 15% displayed gingival
recession. Thus, in a private practice setting, immediately placed and
restored implant success has been demonstrated among a diverse
group of periodontal practitioners.
With these recorded successes of immediate implant placement
by clinicians and researchers, technique refinements and updated rec‐
ommendations have become the new focus for the future of implant
placement in the esthetic zone. Recently, a team of USA‐based clini‐
cians defined the 10 keys to success with immediate implant place‐
ment. These keys stressed the importance of soft tissue thickness
and soft tissue grafting as the key steps to success when focused on
the esthetic zone.50 In two summary reports, 10 essential key items,
which were not recognized in previous systematic reviews, were
identified for success.49,50 The authors reviewed and summarized
the available evidence with the intent to provide guidance and evi‐
dence‐based support to successful immediate implants in the esthetic
zone. Table 1 presents a summary from the contribution of multiple
clinicians for a change in the paradigm of parameters for successful
incorporation of immediate implant placement in the esthetic zone.
7 | D I A B E TE S M E LLIT U S A N D D E NTA L
I M PL A NT TH E R A PY: A PA R A D I G M S H I F T
As we continue to challenge the underpinnings of dental implant
therapy, we advance the use of implant therapy for the benefit of
our patients. Another area of advancement is the broader applica‐
tion of implant therapy for the benefit of our patients who may have
otherwise been excluded because of systemic risk factors. One of
the most considered systemic conditions in challenging our use of
implant therapy has been as a relative contraindication for patients
with diabetes mellitus.
8 | D I A B E TE S M E LLIT U S A S A R E L ATI V E
CO NTR A I N D I C ATI O N
Diabetes mellitus is a condition that affects millions of people
around the world. Recently, over 30 million Americans, representing
 |
232       SAITO et al.

TA B L E 2   Evidence‐based considerations for implant therapy management of patients with poorly controlled diabetes

Clinical consideration Management References Limitations

91
Healing and infection Antibiotics (1 wk) and local anti‐ Dowell et al, 2007 ; Oates et Specific benefits of antibiotics and antimi‐
after surgery microbial rinse (2 wk) al, 201497 crobials in postsurgical regimen for these
patients unknown
Osseointegration Delays with elevated HbA1c Oates et al, 200994; 201497 Effects of restoration without modification for
(short‐term) (>8.0%) delays unknown
Osseointegration No compromises noted with Khandelwal et al, 201395; Eskow Limited evidence available of long‐term
(long‐term) normal function and Oates, 201796; Oates et al, survival
201497
Peri‐implant infection Potential for increased risk for See Table 4 Limited evidence available specific to glycemic
marginal bone loss status

almost 10% of the US population, were estimated as having diabetes
in 2015, with new cases being diagnosed at a rate of 1.5 million per
year.64 As this expanding population of diabetic patients is depend‐
ent on dietary management for overall control of their diabetic con‐
dition, the support of optimal oral health and function has increased
the importance of the role for oral healthcare providers in the overall
well‐being of their patients.
There have been several key studies that have provided support
for dental implant therapy in patients with diabetes.65-70 One study,
which evaluated 89 diabetic patients over 2 years following implant
support for complete dentures, identified significant benefits in
chewing function and general patient satisfaction.69 While not the
main focus of the study, no implant failures were reported, and only
limited implant‐related biologic complications were noted, thereby
suggesting the potential for successful implant therapy in patients
with diabetes.
In spite of these favorable reports of implant survival for
patients with diabetes, a substantial body of literature urged
caution in the utilization of implant therapy for patients with di‐
abetes. In 1988, the first National Institutes of Health Consensus
Conference on dental implants identified diabetes as a relative
contraindication, based on glycemic control, for dental implant
therapy.71 This was reaffirmed in 1996 at the World Workshop in
Periodontics, supporting the longstanding paradigm that although
well‐controlled diabetic patients may be considered appropriate
for implant therapy, diabetic patients lacking good glycemic con‐
trol may be denied the benefits of implant therapy.72 However,
a more recent critical evaluation of the existing literature and
several investigations raised doubt as to the true risk of adverse
consequences because of hyperglycemia, in contrast to the poten‐
tial benefits for broader application of implant therapy for individ‐
uals with diabetes.73,74
This critical review revealed that eight of the 16 studies evaluat‐
ing implant therapy in patients with diabetes either did not quantita‐
tively assess glycemic control or did not mention how they defined
or reported patients as well‐controlled.75-82 Two studies assessed
diabetic status with blood glucose testing that provided a narrow
perspective of glycemic management.80,83 In two additional studies,
patients were encouraged to maintain good glycemic control, but di‐
abetic status was determined by patient report, without any specific
assessment of glycemic status.75,78 Given the lack of a clear assess‐
ment or reporting of glycemic status and the inconsistency in im‐
plant survival rates, which ranged from 0% to 14% in these studies,
this review concluded that observations taken from existing litera‐
ture did not provide meaningful insights into developing contraindi‐
cations for implant therapy based on glycemic status.74
Another major limitation identified in many of these studies
was the lack of a nondiabetic control group.76,77 In fact, only three
studies up to that time comparatively assessed implant success in
a nondiabetic control population, with little difference identified
in implant failure rates between diabetic patients (2.8%‐7.8%) and
nondiabetic patients (1.9%‐6.8%).84-86 Although the overall risk of
implant failure remained in question, several authors had concerns,
specifically with early implant failures within the first year follow‐
ing placement, rather than later failure following the longer term
functioning of implants.66,84,87-90 These studies supported concerns

TA B L E 3   Time needed for implant stability to return following placement level (based on107)

Less stable implant at Increase in time needed for More stable implant at Increase in time needed for
HbA1c level (%) baseline (wk)a integrationb (%) baseline (wk) integrationb (%)

<6.0 3.8 — 2.4 —

6.0‐8.0 4.0 105 2.8 117
>8.0 7.3 192 5.4 225
a
Determined as the calculated time in weeks for implant stability to equal or exceed baseline stability. Two implants were placed per patient in the
edentulous mandible.
b
Calculated as percentage of time in weeks for diabetes groups divided by the control group (HbA1c < 6.0%).
SAITO et al.
F I G U R E 8   Changes in implant stability quotient (%) from
baseline by HbA1c level and time following implant placement.
( HbA1c ≤ 8.0% [n = 22 individuals]; HbA1c ≥ 8.1% [n = 10
individuals]). Error bars represent SE. * indicates HbA1c ≥ 8.1%
significantly (P ≤ 0.05) different from HbA1c ≤ 8.0% at the same
follow‐up time. + indicates significant (P ≤ 0.05) change from
baseline for the same HbA1c group. (With permission, Figure 2,
reference 94)
F I G U R E 9   Implant overdenture patient with poorly controlled
diabetes (presurgery HbA1c at 9.6%) 3 y following restoration with
abutments [Colour figure can be viewed at wileyonlinelibrary.com]
regarding metabolic compromises in the osseous healing associated
with the implant integration process.76,77,82 Two of these studies
documented a 7%‐14% implant failure rate within the first year of
function. 66,87
In summary, a critical assessment of existing literature
TA B L E 4   Recent systematic reviews
evaluating implant survival
References
108
Moraschini et al
Naujokat et al109
Shi et al110
|
      233
identified significant deficiencies, demonstrating the need to clarify
the parameters and factors which affect the success of implants in
diabetic patients relative to levels of glycemic control.
9 | TH E I M PAC T O F G LYC E M I C CO NTRO L
O N S U CC E S S FU L I M PL A NT TR E ATM E NT
With greater awareness of the necessity to measure glycemic lev‐
els through HbA1c to appropriately judge systemic effects on the
long‐term healing process, several research groups targeted existing
paradigms for implant therapy in patients with diabetes. Consistent
with previous studies, these recent studies reported a wide range of
implant failure rates, from 0% to 9.1%. However, these studies better
documented glycemic status and extended their inclusion criteria to
patients with moderate to poor glycemic control.91-93
The first of these recent studies included patients with previ‐
ously excluded ranges of poor glycemic control.91 As there were
no existing data to support implant therapy in poorly controlled
patients, this pilot study employed an “exposure escalation” design
in which 25 implant patients were successively enrolled, including
15 patients with HbA1c levels above 8.0% at the time of surgery.
This study therefore included patients outside the “well‐controlled”
comfort zone of previous studies, and included three patients with
HbA1c levels above 10.0%. Most importantly for this pilot study, all
patients experienced successful healing of their implants over an
initial 4‐month healing period prior to restoration, and a successful
restoration result (Figure 7A,B, Table 2).91 Furthermore, using the
longitudinal assessment of stability, for the first time in humans this
study identified significant compromises in the local bone metabo‐
lism during implant integration in direct relation to HbA1c levels.94
This pilot study was pivotal in shifting the paradigm for several
reasons.91 First, a threshold of an HbA1c level greater than 8.0% for
these effects was demonstrated as having direct clinical implications
on implant healing (Figure 8). Second, it showed that longitudinal
assessments using resonance frequency analysis could provide a
specific picture of the biologic interplay at the bone‐implant inter‐
face during the period of active implant integration. Importantly, this
approach provided a picture sensitive enough to discriminate the ef‐
fects of elevated glycemic levels. Third, this pilot study was ground‐
breaking in that it supported continued investigation into the role
of elevated glycemic levels in guiding the therapeutic application of
Number of in‐
cluded studies Study conclusion
14 Rate of implant failure is not higher for diabetic
subjects than for nondiabetic subjects
18 Dental implants are safe and predictable proce‐
dures for dental rehabilitation in diabetics
7 The failure rate in patients with diabetes that
was not well controlled was not higher than in
patients with well‐controlled diabetes
 |
234       SAITO et al.

TA B L E 5   Recent systematic reviews

Number of in‐
evaluating peri‐implant disease
References cluded studies Study conclusion

Dreyer et al103 5 The patients with diabetes mellitus were 2 times

more likely to have peri‐implantitis compared with
those without diabetes mellitus (effect summary OR
2.5, 95% CI 1.4‐4.5)
Moraschini et al108 4 A statistically significant difference was observed in
favor of the nondiabetic group, with a mean differ‐
ence in marginal bone loss of 0.18 mm
Naujokat et al109 5 The conclusions are quite heterogeneous.
In the first years after implant insertion, there seems
to be no elevated risk of peri‐implantitis; but in the
long‐term observation, peri‐implant inflammation
seems to be increased in diabetic patients

dental implant therapy for patients with poor glycemic control who
would normally otherwise be denied the benefits of this treatment
approach.94
Several more recent studies have reinforced the use of dental
implants in patients with glycemic levels elevated beyond therapeu‐
92,93,95-97
tic targets. One study evaluated the 1‐year postloading re‐
sults for a larger, prospective cohort study.97 This study reported on
117 edentulous patients each receiving two implants (234 implants)
for implant‐supported mandibular overdentures (Figure 9). Baseline
(surgical) HbA1c values ranged from 5.1% to 11.1%. Only two of the
234 implants placed failed to integrate over this 1‐year postload‐
ing period, with no failures in the 20 patients with poor glycemic
control.97 This larger study directly confirmed the findings of the
original pilot study by reporting no adverse clinical outcomes for
the implants placed in poorly controlled diabetic patients, and by
verifying the 8.0% HbA1c threshold with a twofold increase in the
time to integration for those patients exceeding this HbA1c level
(Table 3).91
Several more recent studies have concluded that diabetic patients
may have similar positive outcomes to those found with healthy, non‐
diabetic patients.98-102 Their findings have led to a more rigorous and
open scientific investigation of the impact systemic factors have on
implant therapy success. It is a positive sign that several recent inves‐
tigations have begun to focus not only on implant survival, but also on
implant‐related biologic complications, including long‐term implant
maintenance and the potential consequences of implant therapy under
function within the oral environment (Table 4).99,100,103,104 Recent sys‐
tematic reviews have begun to address the potential for long‐term
implant sequelae associated with diabetes (Table 5).99,100,103,104 As
peri‐implantitis remains a concern for implant therapy, it appears that
diabetes may add risk to this complication, even although studies are
heterogeneous and the results across these reviews are not consistent.
Additionally, with many recent findings supporting a reduced
risk of complications with implant therapy for patients lacking gly‐
cemic levels approaching therapeutic targets, it raises an important
question on the other side of the risk‐benefit equation. That is, to
begin to fully and appropriately operationalize implant therapy for
medically compromised patients, we will need not only to continue
to challenge existing dogma and fully define the long‐term risks,
but will also need to understand the benefits gained from implant
therapy as an important contribution to improved oral and systemic
health.97,105,106 It is perhaps one of the more subtle contributions
from these earlier studies challenging the longstanding implications
for diabetes in implant therapy that it has taken forward similar con‐
siderations across a range of systemic conditions.98,103,105
Going forward, there is a clear trend of newer studies offering
more stringent scientific documentation of the impact of diabetes
and glycemic status on implant survival, with many of these studies
finding positive results for implant integration and survival. This has
enabled a focus on long‐term sequelae, including risks for peri‐im‐
plantitis and mucositis. Additionally, it supports greater scrutiny of
implant therapy relative to other systemic conditions while looking
more broadly at both the risks and benefits of implant therapy for
our patients across a broad spectrum of need.
10 | S U M M A RY
When considering the evolution of dental implant therapy, with
a focus on contributions from the USA and North America, it has
become clear that as the early operational paradigms for implant
therapy have been challenged, these challenges have fostered im‐
portant advances in implant care. This paper has reviewed the ad‐
vancements in understanding the implant‐soft tissue interface with
greater emphasis on esthetic outcomes, the potential for greater
immediacy in delivery of care, and the potential for a much broader
application of implant therapy for patients previously considered
at too great a risk for implants because of systemic conditions. The
interests of many researchers and clinicians, regardless of geog‐
raphy, have been critical in defining where we are today, and will
guide where we will be tomorrow. By challenging earlier paradigms
and dogma for successful implant therapy, there continues to be
scientific advancement within the field, both in implant design and
application, and most importantly in patient‐related outcomes.
Ultimately, these changes have contributed to more patient‐friendly
approaches to care and greater opportunities for patients to benefit
from this care.
SAITO et al.
C O N FL I C T O F I N T E R E S T
The authors report that they have no conflicts of interest related to
this paper.
REFERENCES
1. Evans CD, Chen ST. Esthetic outcomes of immediate implant
placements. Clin Oral Implant Res. 2008;19(1):73‐80.
2. Cosyn J, De Bruyn H, Cleymaet R. Soft tissue preservation and pink
aesthetics around single immediate implant restorations: a 1‐year
prospective study. Clin Implant Dent Relat Res. 2013;15(6):847‐857.
3. Raes F, Cosyn J, Crommelinck E, Coessens P, De Bruyn H.
Immediate and conventional single implant treatment in the ante‐
rior maxilla: 1‐year results of a case series on hard and soft tissue
response and aesthetics. J Clin Periodontol. 2011;38(4):385‐394.
4. Meijndert CM, Raghoebar GM, Meijndert L, Stellingsma K, Vissink
A, Meijer HJ. Single implants in the aesthetic region preceded by
local ridge augmentation; a 10‐year randomized controlled trial.
Clin Oral Implant Res. 2017;28(4):388‐395.
5. Cochran DL, Hermann JS, Schenk RK, Higginbottom FL, Buser
D. Biologic width around titanium implants. A histometric analy‐
sis of the implanto‐gingival junction around unloaded and loaded
nonsubmerged implants in the canine mandible. J Periodontol.
1997;68(2):186‐198.
6. Berglundh T, Lindhe J. Dimension of the periimplant mucosa.
Biological width revisited. J Clin Periodontol. 1996;23(10):971‐973.
7. Branemark PI, Adell R, Breine U, Hansson BO, Lindstrom J, Ohlsson
A. Intra‐osseous anchorage of dental prostheses. I. Experimental
studies. Scand J Plast Reconstr Surg. 1969;3(2):81‐100.
8. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of
bone, connective tissue, and epithelium to endosteal implants with
titanium‐sprayed surfaces. J Maxillofac Surg. 1981;9(1):15‐25.
9. Jones AA, Cochran DL. Consequences of implant design. Dent Clin
North Am. 2006;50(3):339‐360, v.
10. Hermann JS, Buser D, Schenk RK, Cochran DL. Crestal bone
changes around titanium implants. A histometric evaluation of
unloaded non‐submerged and submerged implants in the canine
mandible. J Periodontol. 2000;71(9):1412‐1424.
11. Hermann JS, Buser D, Schenk RK, Schoolfield JD, Cochran DL.
Biologic Width around one‐ and two‐piece titanium implants. Clin
Oral Implant Res. 2001;12(6):559‐571.
12. Hermann JS, Buser D, Schenk RK, Higginbottom FL, Cochran DL.
Biologic width around titanium implants. A physiologically formed
and stable dimension over time. Clin Oral Implant Res. 2000;11(1):1‐11.
13. Hermann JS, Jones AA, Bakaeen LG, Buser D, Schoolfield JD,
Cochran DL. Influence of a machined collar on crestal bone
changes around titanium implants: a histometric study in the ca‐
nine mandible. J Periodontol. 2011;82(9):1329‐1338.
14. Tarnow D, Elian N, Fletcher P, et al. Vertical distance from the crest
of bone to the height of the interproximal papilla between adja‐
cent implants. J Periodontol. 2003;74(12):1785‐1788.
15. Albrektsson T, Jansson T, Lekholm U. Osseointegrated dental im‐
plants. Dent Clin North Am. 1986;30(1):151‐174.
16. Hanggi MP, Hanggi DC, Schoolfield JD, Meyer J, Cochran DL,
Hermann JS. Crestal bone changes around titanium implants. Part
I: A retrospective radiographic evaluation in humans comparing
two non‐submerged implant designs with different machined col‐
lar lengths. J Periodontol. 2005;76(5):791‐802.
17. Broggini N, McManus LM, Hermann JS, et al. Persistent acute
inflammation at the implant‐abutment interface. J Dent Res.
2003;82(3):232‐237.
18. Broggini N, McManus LM, Hermann JS, et al. Peri‐implant inflam‐
mation defined by the implant‐abutment interface. J Dent Res.
2006;85(5):473‐478.
|
      235
19. Cochran DL, Mau LP, Higginbottom FL, et al. Soft and hard tissue
histologic dimensions around dental implants in the canine re‐
stored with smaller‐diameter abutments: a paradigm shift in peri‐
implant biology. Int J Oral Maxillofac Implants. 2013;28(2):494‐502.
20. Bakaeen L, Quinlan P, Schoolfield J, Lang NP, Cochran DL. The bi‐
ologic width around titanium implants: histometric analysis of the
implantogingival junction around immediately and early loaded
implants. Int J Periodontics Restorative Dent. 2009;29(3):297‐305.
21. Tarnow DP, Cho SC, Wallace SS. The effect of inter‐implant dis‐
tance on the height of inter‐implant bone crest. J Periodontol.
2000;71(4):546‐549.
22. Lazzara RJ, Porter SS. Platform switching: a new concept in im‐
plant dentistry for controlling postrestorative crestal bone levels.
Int J Periodontics Restorative Dent. 2006;26(1):9‐17.
23. Canullo L, Rasperini G. Preservation of peri‐implant soft and hard
tissues using platform switching of implants placed in immediate
extraction sockets: a proof‐of‐concept study with 12‐ to 36‐month
follow‐up. Int J Oral Maxillofac Implants. 2007;22(6):995‐1000.
24. Schwarz F, Hegewald A, Becker J. Impact of implant‐abutment
connection and positioning of the machined collar/microgap on
crestal bone level changes: a systematic review. Clin Oral Implant
Res. 2014;25(4):417‐425.
25. Cochran DL, Schou S, Heitz‐Mayfield LJ, Bornstein MM, Salvi
GE, Martin WC. Consensus statements and recommended clini‐
cal procedures regarding risk factors in implant therapy. Int J Oral
Maxillofac Implants. 2009;24(Suppl):86‐89.
26. Wagenberg B, Froum SJ. Prospective study of 94 platform‐
switched implants observed from 1992 to 2006. Int J Periodontics
Restorative Dent. 2010;30(1):9‐17.
27. Berglundh T, Abrahamsson I, Welander M, Lang NP, Lindhe J.
Morphogenesis of the peri‐implant mucosa: an experimental study
in dogs. Clin Oral Implant Res. 2007;18(1):1‐8.
28. Linkevicius T, Puisys A, Steigmann M, Vindasiute E, Linkeviciene L.
Influence of vertical soft tissue thickness on crestal bone changes
around implants with platform switching: a comparative clinical
study. Clin Implant Dent Relat Res. 2014;17:1228‐1236.
29. Saito H, Chu SJ, Zamzok J, et al. Flapless postextraction socket
implant placement: the effects of a platform switch‐designed im‐
plant on peri‐implant soft tissue thickness‐a prospective study. Int
J Periodontics Restorative Dent. 2018;38(Suppl):s9‐s15.
30. Vandeweghe S, De Bruyn H. A within‐implant comparison to eval‐
uate the concept of platform switching: a randomised controlled
trial. Eur J Oral Implantol. 2012;5(3):253‐262.
31. Suarez‐Lopez Del Amo F, Lin GH, Monje A, Galindo‐Moreno
P, Wang HL. Influence of soft tissue thickness on peri‐implant
marginal bone loss: a systematic review and meta‐analysis. J
Periodontol. 2016;87(6):690‐699.
32. Abrahamsson I, Welander M, Linder E, Berglundh T. Healing at im‐
plants placed in an alveolar ridge with a sloped configuration: an ex‐
perimental study in dogs. Clin Implant Dent Relat Res. 2014;16(1):62‐69.
33. Welander M, Abrahamsson I, Berglundh T. Subcrestal placement
of two‐part implants. Clin Oral Implant Res. 2009;20(3):226‐231.
34. Nevins M, Kim DM, Jun SH, Guze K, Schupbach P, Nevins ML.
Histologic evidence of a connective tissue attachment to laser mi‐
crogrooved abutments: a canine study. Int J Periodontics Restorative
Dent. 2010;30(3):245‐255.
35. Kan JYK, Rungcharassaeng K, Deflorian M, Weinstein T, Wang
HL, Testori T. Immediate implant placement and provisional‐
ization of maxillary anterior single implants. Periodontol 2000.
2018;77(1):197‐212.
36. Lazzara RJ. Immediate implant placement into extraction sites:
surgical and restorative advantages. Int J Periodontics Restorative
Dent. 1989;9(5):332‐343.
37. Yukna RA. Clinical comparison of hydroxyapatite‐coated titanium
dental implants placed in fresh extraction sockets and healed sites.
J Periodontol. 1991;62(7):468‐472.
 |
236       SAITO et al.
38. Becker BE, Becker W, Ricci A, Geurs N. A prospective clinical trial of
endosseous screw‐shaped implants placed at the time of tooth ex‐
traction without augmentation. J Periodontol. 1998;69(8):920‐926.
39. Wilson TG Jr, Schenk R, Buser D, Cochran D. Implants placed
in immediate extraction sites: a report of histologic and histo‐
metric analyses of human biopsies. Int J Oral Maxillofac Implants.
1998;13(3):333‐341.
40. Fugazzotto PA. Immediate implant placement and GBR in hu‐
mans: a case report and histologic evaluation. Int J Periodontics
Restorative Dent. 1999;19(5):457‐463.
41. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded im‐
plants at stage 1 surgery in edentulous arches: ten consecutive
case reports with 1‐ to 5‐year data. Int J Oral Maxillofac Implants.
1997;12(3):319‐324.
42. Garber DA, Salama MA, Salama H. Immediate total tooth replace‐
ment. Compend Contin Educ Dent. 2001;22(3):210‐216, 218.
43. Tarnow DP, Magner AW, Fletcher P. The effect of the distance
from the contact point to the crest of bone on the presence
or absence of the interproximal dental papilla. J Periodontol.
1992;63(12):995‐996.
44. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and
provisionalization of maxillary anterior single implants: 1‐year pro‐
spective study. Int J Oral Maxillofac Implants. 2003;18(1):31‐39.
45. West JD, Oates TW. Identification of stability changes for im‐
mediately placed dental implants. Int J Oral Maxillofac Implants.
2007;22(4):623‐630.
46. Norton MR. The influence of insertion torque on the survival of
immediately placed and restored single‐tooth implants. Int J Oral
Maxillofac Implants. 2011;26(6):1333‐1343.
47. Kan JY, Roe P, Rungcharassaeng K. Effects of implant morphology
on rotational stability during immediate implant placement in the
esthetic zone. Int J Oral Maxillofac Implants. 2015;30(3):667‐670.
48. Fugazzotto PA. Treatment options following single‐rooted tooth
removal: a literature review and proposed hierarchy of treatment
selection. J Periodontol. 2005;76(5):821‐831.
49. Levine RA, Ganeles J, Gonzaga L, et al. 10 keys for successful es‐
thetic‐zone single immediate implants. Compend Contin Educ Dent.
2017;38(4):248‐260.
50. Levine RA, Ganeles J, Kan J, Fava PL. 10 keys for successful es‐
thetic‐zone single implants: importance of biotype conversion for
lasting success. Compend Contin Educ Dent. 2018;39(8):522‐529;
quiz 530.
51. Chen ST, Wilson TG Jr, Hammerle CH. Immediate or early place‐
ment of implants following tooth extraction: review of biologic
basis, clinical procedures, and outcomes. Int J Oral Maxillofac
Implants. 2004;19(Suppl):12‐25.
52. Fugazzotto PA. Implant placement at the time of mandibular molar
extraction: description of technique and preliminary results of 341
cases. J Periodontol. 2008;79(4):737‐747.
53. Fugazzotto PA. Implant placement at the time of maxillary molar
extraction: treatment protocols and report of results. J Periodontol.
2008;79(2):216‐223.
54. Lee CT, Chiu TS, Chuang SK, Tarnow D, Stoupel J. Alterations of
the bone dimension following immediate implant placement into
extraction socket: systematic review and meta‐analysis. J Clin
Periodontol. 2014;41(9):914‐926.
55. Stoupel J, Lee CT, Glick J, Sanz‐Miralles E, Chiuzan C, Papapanou
PN. Immediate implant placement and provisionalization in the
aesthetic zone using a flapless or a flap‐involving approach: a ran‐
domized controlled trial. J Clin Periodontol. 2016;43(12):1171‐1179.
56. Tarnow DP, Chu SJ, Salama MA, et al. Flapless postextraction
socket implant placement in the esthetic zone: part 1. The effect of
bone grafting and/or provisional restoration on facial‐palatal ridge
dimensional change‐a retrospective cohort study. Int J Periodontics
Restorative Dent. 2014;34(3):323‐331.
57. Chu SJ, Salama MA, Garber DA, et al. Flapless postextraction
socket implant placement, Part 2: the effects of bone grafting
and provisional restoration on peri‐implant soft tissue height and
thickness‐ a retrospective study. Int J Periodontics Restorative Dent.
2015;35(6):803‐809.
58. Gelb DA. Benchmark for tooth replacement: immediate im‐
plant with immediate provisional restoration. Outcome analyt‐
ics from 29 years of documentation. Compend Contin Educ Dent.
2018;39(7):469‐481.
59. Tonetti MS, Cortellini P, Graziani F, et al. Immediate versus de‐
layed implant placement after anterior single tooth extraction:
the timing randomized controlled clinical trial. J Clin Periodontol.
2017;44(2):215‐224.
60. Mello CC, Lemos CAA, Verri FR, Dos Santos DM, Goiato MC,
Pellizzer EP. Immediate implant placement into fresh extraction
sockets versus delayed implants into healed sockets: a sys‐
tematic review and meta‐analysis. Int J Oral Maxillofac Surg.
2017;46(9):1162‐1177.
61. van Kesteren CJ, Schoolfield J, West J, Oates T. A prospective ran‐
domized clinical study of changes in soft tissue position following
immediate and delayed implant placement. Int J Oral Maxillofac
Implants. 2010;25(3):562‐570.
62. Huynh‐Ba G, Meister DJ, Hoders AB, et al. Esthetic, clinical and
patient‐centered outcomes of immediately placed implants (Type
1) and early placed implants (Type 2): preliminary 3‐month results
of an ongoing randomized controlled clinical trial. Clin Oral Implant
Res. 2016;27(2):241‐252.
63. Scheyer ET, Richardson C, Mandelaris G, et al. Retrospective study
to determine patient satisfaction of immediately placed and provi‐
sionalized implants in the esthetic zone from a US Private‐Practice
Research Network. Compend Contin Educ Dent. 2017;38(2):e9‐e12.
64. Statistics About Diabetes. http://www.diabe​tes.org/diabe​tes-ba‐
sic​s/stati​stics/​?loc=db-slabnav. Accessed September 10, 2019.
65. Smith RA, Berger R, Dodson TB. Risk factors associated with den‐
tal implants in healthy and medically compromised patients. Int J
Oral Maxillofac Implants. 1992;7(3):367‐372.
66. Shernoff AF, Colwell JA, Bingham SF. Implants for type II diabetic
patients: interim report. VA Implants in Diabetes Study Group.
Implant Dent. 1994;3(3):183‐185.
67. Garrett NR, Kapur KK, Hamada MO, et al. A randomized clinical
trial comparing the efficacy of mandibular implant‐supported
overdentures and conventional dentures in diabetic patients.
Part II. Comparisons of masticatory performance. J Prosthet Dent.
1998;79(6):632‐640.
68. Kapur KK, Garrett NR, Hamada MO, et al. A randomized clinical
trial comparing the efficacy of mandibular implant‐supported
overdentures and conventional dentures in diabetic patients.
Part I: methodology and clinical outcomes. J Prosthet Dent.
1998;79(5):555‐569.
69. Kapur KK, Garrett NR, Hamada MO, et al. Randomized clinical
trial comparing the efficacy of mandibular implant‐supported
overdentures and conventional dentures in diabetic patients.
Part III: comparisons of patient satisfaction. J Prosthet Dent.
1999;82(4):416‐427.
70. Garg AK, Winkler S, Bakaeen LG, Mekayarajjananonth T. Dental
implants and the geriatric patient. Implant Dent. 1997;6(3):168‐173.
71. National Institutes of Health Consensus Development Conference
statement on dental implants June 13‐15, 1988. J Dent Educ.
1988;52(12):824‐827.
72. Fritz ME. Implant therapy II. Ann Periodontol. 1996;1(1):796‐815.
73. Oates TW, Huynh‐Ba G. Diabetes effects on dental implant sur‐
vival. Forum Implantol. 2012;8(2):7‐14.
74. Oates TW, Huynh‐Ba G, Vargas A, Alexander P, Feine J. A critical
review of diabetes, glycemic control, and dental implant therapy.
Clin Oral Implant Res. 2013;24(2):117‐127.
SAITO et al.
75. Balshi TJWG. Dental implants in the diabetic patient: a retrospec‐
tive study. Implant Dent. 1999;8:355‐359.
76. Shernoff AFCJ, Bingham SF. Implants for type ii diabetic patients:
interim report. VA implants in diabetes study group. Implant Dent.
1994;3:183‐185.
77. Fiorellini JPCP, Nevins M, Nevins ML. A retrospective study of
dental implants in diabetic patients. Int J Periodontics Restorative
Dent. 2000;20:366‐373.
78. Farzad PAL, Nyberg J. Dental implant treatment in diabetic pa‐
tients. Implant Dent. 2002;11:262‐267.
79. van Steenberghe DJR, Desnyder M, Maffei G, Quirynen M. The
relative impact of local and endogenous patient‐related factors
on implant failure up to the abutment stage. Clin Oral Implant Res.
2002;13:617‐622.
80. Peled MAL, Tagger‐Green N, Gutmacher Z, Machtei EE. Dental
implants in patients with type 2 diabetes mellitus: a clinical study.
Implant Dent. 2003;12:116‐122.
81. Moy PK, Medina D, Shetty V, Aghaloo TL. Dental implant failure
rates and associated risk factors. Int J Oral Maxillofac Implants.
2005;20(4):569‐577.
82. Morris HFOS, Winkler S. Implant survival in patients with type 2 di‐
abetes: placement to 36 months. Ann Periodontol. 2000;5:157‐165.
83. Abdulwassie HDP. Diabetes mellitus and dental implants: a clinical
study. Implant Dent. 2002;11:83‐86.
84. Morris HF, Ochi S, Winkler S. Implant survival in patients with
type 2 diabetes: placement to 36 months. Ann Periodontol.
2000;5(1):157‐165.
85. Anner R, Grossmann Y, Anner Y, Levin L. Smoking, diabetes melli‐
tus, periodontitis, and supportive periodontal treatment as factors
associated with dental implant survival: a long‐term retrospective
evaluation of patients followed for up to 10 years. Implant Dent.
2010;19(1):57‐64.
86. Alsaadi G, Quirynen M, Komarek A, van Steenberghe D. Impact
of local and systemic factors on the incidence of late oral implant
loss. Clin Oral Implant Res. 2008;19(7):670‐676.
87. Fiorellini JP, Chen PK, Nevins M, Nevins ML. A retrospective study
of dental implants in diabetic patients. Int J Periodontics Restorative
Dent. 2000;20(4):366‐373.
88. Farzad P, Andersson L, Nyberg J. Dental implant treatment in dia‐
betic patients. Implant Dent. 2002;11(3):262‐267.
89. Peled M, Ardekian L, Tagger‐Green N, Gutmacher Z, Machtei EE.
Dental implants in patients with type 2 diabetes mellitus: a clinical
study. Implant Dent. 2003;12(2):116‐122.
90. Olson JW, Shernoff AF, Tarlow JL, Colwell JA, Scheetz JP, Bingham
SF. Dental endosseous implant assessments in a type 2 diabetic
population: a prospective study. Int J Oral Maxillofac Implants.
2000;15(6):811‐818.
91. Dowell S, Oates TW, Robinson M. Implant success in people with
type 2 diabetes mellitus with varying glycemic control: a pilot
study. J Am Dent Assoc. 2007;138(3):355‐361; quiz 397‐358.
92. Tawil G, Younan R, Azar P, Sleilati G. Conventional and advanced
implant treatment in the type II diabetic patient: surgical proto‐
col and long‐term clinical results. Int J Oral Maxillofac Implants.
2008;23(4):744‐752.
93. Turkyilmaz I. One‐year clinical outcome of dental implants placed
in patients with type 2 diabetes mellitus: a case series. Implant
Dent. 2010;19(4):323‐329.
94. Oates TW, Dowell S, Robinson M, McMahan CA. Glycemic control
and implant stabilization in type 2 diabetes mellitus. J Dent Res.
2009;88(4):367‐371.
95. Khandelwal N, Oates TW, Vargas A, Alexander PP, Schoolfield
JD, Alex McMahan C. Conventional SLA and chemically modi‐
fied SLA implants in patients with poorly controlled type 2 dia‐
betes mellitus–a randomized controlled trial. Clin Oral Implant Res.
2013;24(1):13‐19.
|
      237
96. Eskow CC, Oates TW. Dental implant survival and complication
rate over 2 years for individuals with poorly controlled type 2 dia‐
betes mellitus. Clin Implant Dent Relat Res. 2017;19(3):423‐431.
97. Oates TW Jr, Galloway P, Alexander P, et al. The effects of ele‐
vated hemoglobin A(1c) in patients with type 2 diabetes mellitus
on dental implants: survival and stability at one year. J Am Dent
Assoc. 2014;145(12):1218‐1226.
98. Schimmel M, Srinivasan M, McKenna G, Muller F. Effect of ad‐
vanced age and/or systemic medical conditions on dental implant
survival: a systematic review and meta‐analysis. Clin Oral Implant
Res. 2018;29(Suppl 16):311‐330.
99. Ormianer Z, Block J, Matalon S, Kohen J. The effect of moder‐
ately controlled type 2 diabetes on dental implant survival and
peri‐implant bone loss: a long‐term retrospective study. Int J Oral
Maxillofac Implants. 2018;33(2):389‐394.
100. Alasqah MN, Alrabiah M, Al‐Aali KA, et al. Peri‐implant soft tissue
status and crestal bone levels around adjacent implants placed in
patients with and without type‐2 diabetes mellitus: 6 years follow‐
up results. Clin Implant Dent Relat Res. 2018;20(4):562‐568.
101. Al Amri MD, Al‐Rasheed AS, Al‐Kheraif AA, Alfadda SA.
Comparison of clinical, radiographic, and immunologic inflamma‐
tory parameters around dental implants with cement‐retained and
screw‐retained restorations: a 5‐year prospective cohort study in
men. Int J Prosthodont. 2017;30(4):384‐389.
102. Cabrera‐Dominguez J, Castellanos‐Cosano L, Torres‐Lagares D,
Machuca‐Portillo G. A prospective case‐control clinical study of
titanium‐zirconium alloy implants with a hydrophilic surface in pa‐
tients with type 2 diabetes mellitus. Int J Oral Maxillofac Implants.
2017;32(5):1135‐1144.
103. Dreyer H, Grischke J, Tiede C, et al. Epidemiology and risk fac‐
tors of peri‐implantitis: a systematic review. J Periodontal Res.
2018;53(5):657‐681.
104. Monje A, Catena A, Borgnakke WS. Association between diabetes
mellitus/hyperglycaemia and peri‐implant diseases: systematic re‐
view and meta‐analysis. J Clin Periodontol. 2017;44(6):636‐648.
105. Vissink A, Spijkervet F, Raghoebar GM. The medically compro‐
mised patient: are dental implants a feasible option? Oral Dis.
2018;24(1‐2):253‐260.
106. Awad MA, Rashid F, Feine JS, Overdenture Effectiveness Study
Team Consortium. The effect of mandibular 2‐implant overden‐
tures on oral health‐related quality of life: an International
Multicentre Study. Clin Oral Implant Res. 2014;25(1):46‐51.
107. Michalowicz BS, Hyman L, Hou W, et al. Factors associated with the
clinical response to nonsurgical periodontal therapy in people with
type 2 diabetes mellitus. J Am Dent Assoc. 2014;145(12):1227‐1239.
108. Moraschini V, Barboza ES, Peixoto GA. The impact of diabetes on
dental implant failure: a systematic review and meta‐analysis. Int J
Oral Maxillofac Surg. 2016;45(10):1237‐1245.
109. Naujokat H, Kunzendorf B, Wiltfang J. Dental implants and diabe‐
tes mellitus‐a systematic review. Int J Implant Dent. 2016;2(1):5.
110. Shi Q, Xu J, Huo N, Cai C, Liu H. Does a higher glycemic level lead
to a higher rate of dental implant failure?: a meta‐analysis. J Am
Dent Assoc. 2016;147(11):875‐881.
How to cite this article: Saito H, Aichelmann‐Reidy MB, Oates
TW. Advances in implant therapy in North America: Improved
outcomes and application in the compromised dentition.
Periodontol 2000. 2020;82:225–237. https​://doi.org/10.1111/
prd.12319​