Periodoncia Clínica #20 ENG

Scientific journal of the
Sociedad Española de Periodoncia

International Edition
Period II, Year VII, n.º 20
Editor: Ignacio Sanz Martín 2021 / 20
periodonciaclínica
NEW FRONTIERS IN
IMMEDIATE IMPLANTATION
new fron-
Guest editors:
Fabio Vignoletti y Jan Cosyn
tiers in
immedia-
te implan-
tation
ADVERTISING
Presentation
IMMEDIACY,
ALWAYS HAND IN
HAND WITH RIGOUR.
ANTONIO BUJALDÓN, PRESIDENT OF SEPA 2019-2022
THE TECHNOLOGY AND RHYTHM of life of Western societies The appearance of immediate implants presents significant
has familiarized people with a perception of time that is more unknowns in clinical practice. Immediacy has to be compatible
subjective than objective. The immense capacity of machines with rigour and excellence, which require a very high level of
and automatization also condition the adequacy of human skills knowledge and practical skill, as well as a solid knowledge of the
to be able to respond to increasing demands that even border on biological basis of the tissues. Even the clinical equipment and the
altering natural biological rhythms. coordination of the dental team must be considered to ensure the
The perception of the immediate overwhelms the fields of correct training of all the professionals required to intervene in
consumption and even human relationships. And logically also the these surgical techniques.
need to obtain solutions as quickly as possible for any personal And this is where SEPA must fulfil its work and purpose
concern, even when it is related to health. in different areas. First, as shown in this twentieth issue of
In this context, it is common that the dental patient, especially Periodoncia Clínica, by disseminating scientific knowledge and the
when it comes to aesthetic solutions, looks favourably on the available evidence, along with the more relevant clinical protocols
quickest options that involve the least hard work, provided they that can be shared and subjected to future research to corroborate
meet predictable reliability criteria. their effects. Second, by promoting training activities that update
The current times are marked by a general perception of life current clinical knowledge and procedures. And finally, by also
that is very dynamic, even accelerated in some cases, which is not providing accessible and rigorous information to patients about
free of risks or challenges. the reliability of these treatments of clinical excellence.
This is the case with immediate implant therapy, whose In short, continuous education, outreach, and awareness-
development and popularity within dentistry took off after the raising must be accompanied by a cross-cutting area of research
publication in 1989 of Richard Lazzara’s “Immediate implant promotion based on cooperation between universities, the clinical
placement into extraction sites: surgical and restorative world, and businesses, which will eventually have visibility in
advantages”. congresses and courses, from which to update professionals so that
The possibility of cutting treatment time and surgical they can provide the most rigorous and excellent quality of care,
invasiveness is a great advance and challenge for clinicians, thus contributing to improving the quality of life of patients and
who have been trained in applying the novel technique, with the the oral health of the population at large.
consequent evolution of research in this area, over the last two SEPA, periodontology and oral health for everyone.
years.
3
periodonciaclínica
Management Board Editorial committee Editorial committee Scientific magazine of the
SEPA 2019-2022: Clinical Periodontics: Clinical Periodontics: Spanish Society of Periodontology
President: National Editorial Committee: Edited by:

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Executive Director: Gustavo Cabello Guilherme Paes de Barros Carrilho manuscripts. All opinions belong to their
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Administration:
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4
Editorial
THE CULTURE
OF IMMEDIACY.
IGNACIO SANZ MARTÍN, EDITOR OF PERIODONCIA CLÍNICA
IN THE MIDST OF THIS DIGITAL REVOLUTION, which we At Periodoncia Clínica, we have aimed to review the current
live with hyperconnectivity, easy access to information, and state of the subject starting from the latest scientific evidence on
instant satisfaction, it is no surprise that treatments that involve the topic and with the best national and international experts,
fewer interventions, that are more comfortable for the patient, and led by two prestigious guest editors such as Prof. Cosyn and Dr
that reach their objective in a shorter period of time have greater Vignoletti. The goal has been to give and up-to-date view of the
acceptance and take precedence over and others that are longer in topic and provide answers and clinical solutions to our readers,
time and that present greater discomfort for our patients. in the hope of being able to help in the decision-making and in
In implant therapy, the concept of immediacy – especially in opening the range of treatment options for our patients.
the aesthetic zone – has for a long time had a dubious reputation It is clear that some of the proposals presented here do not
in scientific circles. The advantages of reducing the number of benefit from scientific publications with a long follow-up or from
interventions, placing an immediate fixed provision, and reducing randomized clinical trials that can support them, but it is from
the duration of treatment seemed to be overshadowed by the risks this perspective that working hypotheses are created and from
of an aesthetic failure. The dimensional changes associated with which solutions are found to the clinical problems we find on an
tooth extraction, together with the complexity of the technique of everyday basis.
implant placement, were provoking undesirable situations with I hope that you enjoy this issue and I look forward to greeting
implants often placed towards the buccal aspect and with a lack you in the next one. Happy summer!
of hard and soft tissue. Over time, clinical protocols have been
developed to be able to control and minimize these risks. The
use of active implants that facilitate a greater primary stability,
connective-tissue grafts with a high component kamina propria,
the optimization of the three-dimensional position of the implant,
and filling gaps with biomaterials have made the immediate
implant in the aesthetic zone an option with high predictability.
Having taken on board this axiom, today the question no
longer lies in the viability of placing an immediate implant in
situations where there is the presence of the vestibular buccal
wall and optimal soft tissue height, but in situations where these
conditions are not met. In this issue of the journal we present well-
defined protocols for the treatment of type II (without buccal plate)
and Type III (without buccal plate and with recession) sockets
with remarkable clinical success. Iit is clear that immediate
implantology with immediate loading involves a greater risk for
the success of the treatment, for which is continues to be necessary
to understand in which situations it is possible and predictable
and in which situations one should opt for a delayed option or for
an immediate implant without immediate loading.
5
6
ADVERTISING
NEW FRONTIERS IN Periodoncia Clínica
clinical cases 9
Immediate implants in type II alveolar sockets in the aesthetic zone

11
Paulo Fernando Mesquita de Carvalho, Robert Carvalho da Silva, Cássio
Cardona Orth, Guilherme Paes de Barros Carrilho, Julio Cesar Joly
Immediate dentoalveolar restoration for the treatment
25
of type II and type III extraction sockets using triple graft
from maxillary tuberosity: a case series
José Carlos Martins da Rosa, Ariádene Cristina Pértile de Oliveira
Rosa, Luis Antonio Violín Dias Pereira
Trimodal approach: “the predictable, the plausible,
39
and the imponderable”
Gustavo Cabello, David González, Juan Zufía, Juan Mesquida
Critical steps in the implementation of the
61
socket shield technique
index
Philip Staehler, Sophia M. Abraha, Erdem Guelnergiz,
Joel Bastos Sousa, Otto Zuhr, Markus Huerzeler
The influence of CAF and CTG on immediate implant
75
placement. A modified coronal advanced flap in
combination with connective tissue graft in immediate
post-extraction implants
Massimo de Sanctis, Davide Guglielmi
An innovative strategy for immediate implant placement
87
rehabilitation in molar sites: the SSA concept
Gary Finelle
review articles 101
Biological bases of immediate implants

102
Javier Sanz, Fabio Vignoletti, Nicola Discepoli, Javier Núñez,
Mariano Sanz
Surgical and restorative factors in immediate implants
114
Antonio Liñares, Antonio Arnau, Mafalda Brinco, Álvaro Carballo,
Rafael Domínguez, Ana María Rubinos, María Vázquez, Juan Blanco
Long-term soft tissue stability and peri-implant aesthetics
128
following immediate implant placement: a critical review.
Soft tissue outcomes of immediate implants
Jan Cosyn, Lorenz Seyssens
scientific articles of 139

interest to businesses
conclusions 154
From myth to a concrete and predictable clinical reality: new

154
horizons in immediate implantss
7 Fabio Vignoletti, Jan Cosyn
Periodoncia Clínica 2021 / 20 ‘New frontiers in immediate implantation’
02
periodonciaclínica
8
NEW FRONTIERS IN
clinical Immediate implants in type II alveolar sockets in the

aesthetic zone
cases
Paulo Fernando Mesquita de Carvalho, Robert Carvalho
da Silva, Cássio Cardona Orth, Guilherme Paes de Barros
Carrilho, Julio Cesar Joly
Immediate dentoalveolar restoration for the
treatment of type II and type III extraction sockets
using triple graft from maxillary tuberosity: a case
series
José Carlos Martins da Rosa, Ariádene Cristina Pértile de
Oliveira Rosa, Luis Antonio Violín Dias Pereira
Trimodal approach: “the predictable, the plausible,
and the imponderable”
Gustavo Cabello, David González, Juan Zufía,
Juan Mesquida
Critical steps in the implementation of the socket
shield technique
Philip Staehler, Sophia M. Abraha, Erdem Guelnergiz,
Joel Bastos Sousa, Otto Zuhr, Markus Huerzeler
The influence of CAF and CTG on immediate
implant placement. A modified coronal advanced
flap in combination with connective tissue graft in
immediate post-extraction implants.
Massimo de Sanctis, Davide Guglielmi
An innovative strategy for immediate implant
placement rehabilitation in molar sites: the SSA
concept
Gary Finelle
9
10
Clinical case
IMMEDIATE IMPLANTS IN
TYPE II ALVEOLAR SOCKETS
IN THE AESTHETIC ZONE.
PAULO FERNANDO MESQUITA DE CARVALHO, ROBERT CARVALHO DA SILVA,
CÁSSIO CARDONA ORTH, GUILHERME PAES DE BARROS CARRILHO, JULIO CESAR JOLY.
Paulo Fernando Mesquita de Carvalho.

Master’s degree in periodontology, SLMandic.
Coordinator of the Instituto ImplantePerio.
SUMMARY
Robert Carvalho da Silva. Master’s degree in TYPE II ALVEOLAR SOCKETS are characterized clinically by a (partial) bone defect of
periodontology, FOP/Unicamp. Coordinator of a dehiscence type in the buccal wall, without presenting deficiencies in the soft tissues.
the Instituto ImplantePerio. The presence of some type of bone loss of the buccal plate, as well as a thin bone plate,
Cássio Cardona Orth. Master’s degree in have been identified as aesthetic risk factors for the treatment of post-extraction alveolar
periodontology and impantology, SLMandic. sockets with immediate implants.
Doctoral candidate in Periodontology, UFRGS. On the other hand, the possibility of reconstructing the alveolar defects, through
Teacher at the Instituto ImplantePerio. immediate implants using various reconstructive methodologies, has been published,
Guilherme Paes de Barros Carrilho. Master’s presenting favourable clinical results and CBCT analyses.
degree implantology, UNISA. Teacher at the In this article, we present the results of the treatment of a clinical case with a Type
Instituto ImplantePerio. II alveolar socket, using a reconstruction protocol for hard and soft tissues at the time
Julio Cesar Joly.Master’s degree in of immediate implant placement with an immediate provisional. The clinical and CBCT
periodontology, FOP/Unicamp. Coordinator images show the complete reconstruction of the buccal wall, the stability of the gingival
of the master’s degree programmes in margin, and the maintenance of the peri-implant volume, attaining the objectives of the
periodontology and implantology, SLMandic.
proposed procedure.
Coordinator of the Instituto ImplantePerio.
INTRODUCTION
IN ACCORDANCE WITH THE CONSENSUS OF THE ITI GROUP in 2009 and 2014,
post-extraction alveolar sockets can be treated using different protocols according to
the time of installing the implant and the wound-healing time (Chen and Buser 2009;
Correspondence to: Hämmerle et al. 2012; Morton et al. 2014). The most frequently used alternatives are
Paulo Fernando Mesquita de Carvalho immediate implant placement, alveolar ridge preservation, and the early approach (Buser
paulofernando@implanteperio.com.br et al. 2017).
Acknowledgements:
To Dr Wolney Serio Vieira Filho and Lauro de

Paiva Restive Filho for the restorative part of
the treatment.
11 Paulo F. Mesquita Robert Carvalho Cássio Cardona Guilherme Paes Julio Cesar Joly
Periodoncia Clínica
02 2021 / 20 ‘New frontiers in immediate implantation’
There are certain clinical and radiographic criteria that should be analysed to define
the type of surgical approach that is most suitable, as well as the degree of complexity of
each procedure (Buser et al. 2017).
Without doubt, the buccal bone plate is one of the parameters most debated and
investigated by the scientific community, especially the dimensional changes provoked
by extraction, the characteristics of thickness, and the integrity of the bone (Araújo et al.
2005; Tan et al. 2012; Chen and Darby 2016; Chappuis et al. 2017).
The data published in studies, analysing whole alveolar processes in the anterior
region of the maxilla, observed a high incidence of patients who present thin bone <1.0
mm, suggesting that this is a predominant clinical condition in the aesthetic zone (Huynh-
Ba et al. 2010; Januário et al. 2011; El Nahass and Naiem 2014).
In relation to the percentage of alveolar sockets that present some structural damage,
the information is not so clear, but some publications suggest that the presence of alveolar
bone defects seems to be a common condition; furthermore, there seems to be a strong
correction between the cause of extraction and the type of defect (Noelken et al. 2016;
Chen and Darby 2016).
The literature describes different classifications that evaluate the conditions and the
type of alveolar defect. Some consider only the integrity of the hard/soft tissues (Elian
et al. 2007), while others seek to detail more the characteristics of the anatomy, width,
and depth of the defects (Kan et al. 2009; Joly et al. 2015; Da Silva et al. 2015; Kan et al.
2018).
Some publications argue that a thin bone plate or the presence of buccal bone defects
are aesthetic risk factors and consider these parameters to be contraindications for an
approach with immediate implants (Chen and Buser 2009; Buser et al. 2017); on the other
hand, other studies have shown the possibility of achieving good results carrying out the
reconstruction of the alveolar defect at the same time as placing the immediate implant
(Da Rosa et al. 2014; Da Silva et al. 2015; Joly et al. 2015; Sarnachiaro et al. 2015; Slagter
et al. 2016; Meijer et al. 2019).
The diagnosis and definition of the type of defect are extremely important for
determining the treatment alternatives for the socket, as well as the options for
reconstructing the defect. However, an isolated analysis of the presence of a defect in
the bone plate alone should not be a criterion for excluding an approach with immediate
implants. Our aim is to present the result of the treatment of a clinical case performed
on an alveolar socket with an extensive defect in the buccal wall, using an immediate
implant with simultaneous reconstructive procedures, following the evaluation and
treatment protocol proposed by Joly et al. (2015) and Da Silva et al. (2015).
CLINICAL CASE
Diagnosis
A 34-year-old female patient, in good health, referred by her prosthodontist, with pain,
discomfort, and inflammation in the area of the two superior central incisors. When the
medical history was being taken, the patient told us that three years ago she had received
veneers and an endodontic treatment. The clinical examination showed the presence
of a fistula in the zone of the alveolar mucosa, near the apex of tooth 21 (Figure 1) and
during probing we detected a pocket of about 10 mm with bleeding and suppuration
(Figure 2). In the initial periapical radiograph, it was possible to identify a radiolucent
lesion at the apical level (Figure 3). We started a therapy with antibiotics at the first
visit with the aim of eliminating the acute process of the working area and we asked for
a CBCT of the region. In the three-dimensional image, we identified a resorption in the
apex, as well as an image that suggested a root perforation had occurred during root-
canal instrumentation. We also observed a wide bone defect on the whole vestibular face
towards the root apex, confirming the need to extract the tooth (Figure 4).
12
Paulo Fernando Mesquita Immediate implants in type II alveolar sockets in the aesthetic zone Clinical case
de Carvalho et al.
Figure 1.
Initial clinical condition with a fistula in the mucosa, located at the height of the apex of tooth 21.
Figure 2. Figure 3.
Clinical probing showing attachment loss located at the buccal face. The chronification of the fistula is observed Initial peri-apical X-ray showing the peri-apical
after one week of antibiotic therapy. lesion.
Figure 4.
Initial CBCT. We can observe the presence of a bone defect in the whole buccal plate, as well as a type-IV alveolar
13 socket according to the classification of Kan et al. (2011).
Figure 5. Figure 6. Figure 7.

Root extraction using forceps. Remodelling of granulation tissue and mechanical Occlusal view of the socket immediately after
decontamination of the socket with serrated curettes. extraction.
Figures 8, 9 and 10.

Determining the type of defect using the periodontal probe inside and outside the socket; wide/deep defect.

A 2.0 mm burr supported by the palatal bone to Occlusal view, checking the correct positioning of the Installation of the immediate implant, Nobel Active,
guide the drilling only in the residual apical bone. implant. 3.5 x 13.0 mm (Nobel Biocare).
Figure 14.
Occlusal view showing the implant supported in the palatal bone, positioned at 4.0 mm from the gingival
margin (prosthetic reference) and the space sufficient for the reconstruction on the buccal face. 14
de Carvalho et al.

Installations and adjustment of the provisional titanium abutment connected directly to the implant and capture
of the same ceramic crown as immediate provisional.
Surgical and prosthetic procedure

A little over a week after the first visit, the fistula was in the process of remission and
there was no longer suppuration, which enabled the treatment plan to be followed. We
began the surgical procedure making a minimally traumatic extraction using forceps with
short rotational movements until removing the root portion, avoiding causing additional
loss of bone and the minimum amount of damage to the soft tissues (Figure 5). A careful
mechanical decontamination of the socket using serrated curettes was carried out to
remove all the granulation tissue as well as the epithelized path of the fistula (Figure
6). At this point, after confirming that the socket was completely clean (Figure 7), we
needed to identify the type of bone defect using a periodontal probe (Figures 8, 9, and
10). We started the drilling with a lance-shaped burr or a burr of 1.5mm. In this type of
socket (Type IV) (Kan et al. 2011), we need to use a reduced number of burrs (1.5/2.0/2.4
mm) and work with the burrs supporting only the palatal wall, in a way that all the
perforation to anchor the implant is made in the apical portion of the residual bone
(Figure 11). After checking and defining the correct position of the burrs (Figure 12), we
placed the immediate implant (Nobel Active 3.5 x 13.0 mm/Nobel Biocare) with a manual
screwdriver, achieving a primary stability of 45 Ncm (Figure 13). The implant platform
was placed 4.0 mm apical in relation to the gingival margin in line with the prosthetic
planning (Figure 14). We then screwed in the provisional prosthetic component, making
adjustments according to the spaces and we started the prosthetic phase of capturing
the provisional and the adjustments in the critical/subcritical contour using the same
ceramic crown which was removed and adapted (Figures 15, 16, and 17) (Su et al. 2010).
The contacts during the movements of maximum intercuspation and eccentric movements
were eliminated, and a sub-contour of 1.5/2.0 mm was created in the cervical region of the
provisional restoration to create space and allow a change of the gingival margin in the
coronal direction during the provisionalization phase (Clavijo and Blasi 2017).
15

Modified envelope flap; using Tunnelling Instruments, a full-thickness flap was made in the entire area of
keratinized tissue and part of the alveolar mucosa up to the fistula. In the part that is apical and lateral to the
fistula, a partial-thickness flap (mixed flap) was made.
Figure 21. Figures 22 and 23.

Connective-tissue graft removed from the Frontal and occlusal view showing the saturated graft near the gingival margin, stabilized by two horizontal
tuberosity and divided to increase the length of mattress stitches in the base of the papillae.
the form to reach the area of the fistula.
A mixed-thickness modified envelope flap was then made. We started with a full-
thickness flap from the gingival margin using Tunnelling Instruments (tunelizadores)
along the entire length of the keratinized tissue and part of the alveolar mucosa until
reaching the region of the apical fenestration. In the portion of alveolar mucosa, in the
part that was most apical and lateral to the fenestration, a partial-thickness flap was
made to give mobility and advance the tissue coronally without any tension, using the
same tunneller or micro-blades (Figures 18, 19, and 20).
A connective-tissue graft was obtained from the tuberosity and divided to increase its
length (Figure 21). The graft was placed in the internal part of the flap, in a way that one
end was left near the gingival margin, stabilized with horizontal mattress stitches at the
base of the papillae, and the other end of the graft breaking through the area of the fistula
creating a protective barrier (Figures 22 and 23).
Then a resorbable membrane (Creos, Nobel Biocare) was cut and positioned below the
periosteum and the gingival graft, supported on the apical and interproximal bone frames
by a minimum of 3.0 mm on each side (Figures 24, 25 and 26). The whole defect of the
buccal plate and the gap were filled with a bovine bone matrix with collagen (BBMC) (Bio-
Oss Collagen, Geistlich) until reaching the cervical level of the bone ridge, terminating the
surgical phase (Figure 27).
The procedure was complemented with screwing the provisional and closing the
prosthetic hole (Figure 28). In the immediate post-operative CBCT we observed the
implant in an excellent position and the presence of biomaterial re-establishing the defect
in the whole vestibular portion of the alveolar socket (Figure 29).
16
de Carvalho et al.

The resorbable membrane was adapted and inserted folded into the socket. The membrane should be outside
the socket supported by the apical and lateral bone frames by at least 3.0 mm.
Figure 27.
A piece of Bio-Oss Collagen should be cut, adapted, and placed in the position of the bone defect in the buccal
wall, and then all the spaces should be filled with other fragments of BBMC until completely filled.
Figure 29.
CBCT immediately post-operation showing
Figure 28. the correct positioning of the implant and the
Provisional screwed crown with occlusal adjustments and the carefully adjusted cervical contour. biomaterial in the entire buccal defect.
17
Figure 30.
Frontal view six months after the surgical procedure. The gingival margin is presented more coronal than the
initial condition.
Figure 31.
Occlusal view, six months later, where we can observe health in the peri-implant tissues and a volume compatible
with the adjacent teeth.
Figure 32.
Definitive restoration on implant with a favourable aesthetic result. 18
de Carvalho et al.
Figures 33, 34, 35 and 36.

Clinical follow-up, frontal and occlusal view, peri-apical X-ray, and CBCT after about two years. The stability of the results and the reconstruction is observed.
After six months, we could observe the gingival margin of the implant slightly
more coronal compared to the margin of tooth 11 (Figure 30). After the removal of the
provisional crown, there was a volume compatible with the architecture of the adjacent
teeth (Figure 31). To conclude, the prosthetic procedures were completed to make the
definitive crown (Figure 32).
In the clinical images, peri-apical X-rays, and CBCT, we can see the complete
reconstruction of the buccal bone plate and the stability of the volume and of the position
of the gingival margin, demonstrating the aesthetic and functional success of the
treatment after approximately three years of follow-up (Figures 33, 34, 35, and 36).
DISCUSSION
THE PROCESS OF ALVEOLAR CICATRIZATION and the dimensional changes that
follow extraction – independently of the implant placement – have become better known
based on studies in animal models developed since 2003 (Cardaropoli et al. 2003; Araújo
et al. 2005). The scientific focus in recent years has centred above all on the biological
aspects and on the clinical/radiographical characteristics of the buccal bone plate. Clinical
studies and CBCT analysis describe how a large majority of patients (more than 80%)
present a thin (≤1.0 mm) buccal bone plate in the anterior teeth of the maxilla (Huynh-Ba
et al. 2010; Januário et al. 2011; El Nahass and Naiem 2014).
19
The integrity of the alveolar walls is a selection criterion for patients in most of the
research that has evaluated the results of the treatment of post-extraction sockets using
immediate implants. In this condition, the results showed that the portion most affected
by alterations in the volume of the ridge are centred on the buccal wall of the socket,
mainly on the cervical and middle third. According to the studies by Chappuis et al.
(2013, 2017), there seems to be a direct relationship between the width of the walls of the
socket and the amount of bone resorption, as the vertical bone loss in the buccal plate
was about seven times greater when the bone wall presented a thickness ≤1.0 mm. Some
authors advocate a thin buccal bone ≤1.0 mm or the presence of defects on the buccal face
as aesthetic risk factors for treatment with immediate implants and do not recommend
this type of approach because of the possibility of developing complications such as loss of
volume, recession of the gingival margin, or alterations of colour (Kan et al. 2009; Cosyn
et al. 2013; Cosyn et al. 2016; Buser et al. 2017).
However, in the publications that described these problems, the sockets were treated
with immediate implants, but using different protocols both surgical (with/without gap
filling) and prosthetic (with/without provisional, with/without cicatrization abutments).
One important aspect is the none of these publications used connective-tissue grafts as
a treatment protocol, while the results of other studies that added the connective-tissue
graft to the protocol of immediate implants as a form of compensation did not present the
same problems (Rungcharassaeng et al. 2012; Yoshino et al. 2014; Migliorati et al. 2015).
In the same way, a small number of publications have evaluated the potential of
treatment of sockets with defects in the buccal plate using immediate implants (Da Rosa
et al. 2014; Sarnachiaro et al. 2015; Slagter et al. 2016; Assaf et al. 2017; Meijer et al.
2019). In fact, the placement of implants in damaged sockets seems to be an important
discussion as many compromised teeth – especially those in the anterior region of the
maxilla – present some type of bone defect in the buccal bone plate. Although there is
no consensus on the percentage of cases that present defects in the walls of the alveolar
socket, according to Chen and Darby (2016), there seems to be a correlation between the
cause of the extraction (i.e., periodontal disease, fracture, resorption or root perforations,
peri-apical lesions of endodontic origin, caries, etc) and the characteristics of the defect
developed, as well as the magnitude of the bone remodelling after the extraction.
According to Elian et al. (2007), sockets with bone defects in the buccal plate can be
defined as type II and type III, depending on the amount of bone loss (partial or complete)
and the conditions of the soft tissues (with or without recession), respectively. Some other
classifications detail the types of alveolar defects. For instance, Sclar (2004), who classified
defects analysing the horizontal and vertical aspects, and Kan et al. (2009), who classified
dehiscences according to the form. Joly et al. (2015) proposed a classification associating
all these factors and defining seven conditions of the alveolar socket: whole, fenestration,
narrow/short defect, narrow/deep defect, wide/short defect, wide/deep defect, and complex
defect involving the palatine and/or apical bone.
It is important to understand that the success of the bone integration and the
placement of the immediate implant do not depend on the conditions of the buccal bone
plate. The most important factor for defining the possibility of anchoring the implant
in the correct three-dimensional position is the residual bone which, according to the
classification by Kan et al. (2011), can be defined in 4 types, according to the axis of
the root and the format of the palatal and apical bone (residual bone). For this reason,
various publications have shown success in the treatment of sockets with bone defects
using immediate implants, with different protocols for reconstructing the bone defect
(Sarnachiaro et al. 2015; Slagter et al. 2016; Meijer et al. 2019). Some authors carry out
only reconstruction of hard tissue (fragments of autologous bone of the tuberosity (Da
Rosa et al. 2014, Slagter et al. 2016; Meijer et al. 2019), autologous bone particulate
(Noelken et al. 2018), biomaterials with membrane (Da Silva et al. 2015) or without
membrane (Assaf et al. 2017), while others also added reconstruction of soft tissues
(connective-tissue graft) (Joly et al. 2015; Da Silva et al. 2015; Slagter et al. 2016).
20
de Carvalho et al.
The case presented followed the decision tree published by Joly et al. (2015) and Da
Silva et al. (2015), based on the individual analysis of four clinical factors and CBCT: 1.
residual bone (palatal/apical), 2. position of the gingival margin (prosthetic reference), 3.
buccal bone plate (whole or define type of defect), 4. biotype/phenotype (width of the buccal
bone and the soft tissues).
Thus, in type-II alveolar sockets, provided we have residual bone to anchor the
implant in the correct three-dimensional position, we opt to place the immediate implant
without a flap. The classification of the type of bone defect is fundamental for defining the
reconstruction protocol. In wide defects, and especially in deep ones, the reconstruction
of the buccal portion is made with BBMC associated with a resorbable membrane to
maintain the space and allow a good stability of the biomaterials in the wide defects, as
the remnants of the bone wall are further away thus making the defect more critical.
This recommendation is not yet supported by the literature – it is a clinical observation.
In all situations of thin bone or in the presence of a bone defect in the buccal plate we
recommend adding a connective-tissue graft using the technique of modified envelope
flap, to compensate for a probable loss of volume and to avoid recession of the peri-implant
mucosa. Finally, socket sealing should be made with immediate provisional restorations
or personalized healing abutments, carefully adjusted from the occlusal point of view and
in the cervical contour.
CONCLUSION
THE PRESENCE OF BONE DEFECTS in the bone plate seems to be a common clinical
condition and may or may not be associated with soft-tissue deficiencies, characterizing type
II and type III alveolar sockets respectively. Treatment with immediate implants in type-
II sockets has not been recommended in the majority of the guidelines and publications
because of the risk of contamination or aesthetic problems.
However, over time certain paradigms have evolved showing the possibility of attaining
a successful result with immediate implants also in sockets that present some kind of defect
in the buccal wall.
In this publication, we have shown the possibility of reconstructing an extensive bone
defect in the vestibular bone wall using a reconstruction protocol without flap-raising
during the placement of an immediate implant, associating biomaterials, connective-tissue
graft, and an immediate provision, attaining an excellent clinical result.
CLINICAL RELEVANCE
IN POST-EXTRACTION SOCKETS, the presence of different bone defects
in the buccal wall is a common clinical condition which should be carefully
evaluated and treated independently of the placement of an immediate implant.
The reasons for and the types of bone defects should be diagnosed previously
and confirmed immediately after extraction and careful curettage of the socket.
However, more important than the condition of the buccal bone plate is the
evaluation of the residual bone, the position of the gingival margin, and
the placement of the implant in the correct three-dimensional position. If
these critical aspects are respected, it is possible to reconstruct the bone defect
using minimally invasive reconstruction techniques by means of soft- and/or
hard-tissue grafts, simultaneous with the placement of the immediate implant
together with an integrated prosthetic approach.
21
BIBLIOGRAPHICAL REFERENCES
Araújo MG, Sukekava F, Wennström JL, Lindhe J. (2005) Da Silva RC, Joly JC, de Carvalho PFM. (2015) Socket Migliorati M, Amorfini L, Signori A, Biavati AS,
Ridge alterations following implant placement in management in the esthetic zone. Journal of Benedicenti S. (2015). Clinical and aesthetic outcome
fresh extraction sockets: An experimental study in the Comestic Dentistry 31, 110-12. with post-extractive implants with or without soft
dog. Journal of Clinical Periodontology 32, 645-652. tissue augmentation: A 2-year randomized clinical
Elian N, Cho SC, Froum S, Smith RB, Tarnow DP.
Assaf JH, Assaf DC, Antoniazzi RP, Osório LB, França (2007) A simplified socket classification implant and trial. Clinical Implant Dentistry and Related Research
FM. (2017) Correction of buccal dehiscence during repair technique. Practical Procedures & Aesthetic 17, 983-995.
immediate implant placement using the flapless Dentistry 19, 99-104. Morton D, Chen ST, Martin WC, Levine RA, Buser D.
technique: A tomographic evaluation. Journal of (2014) Consensus statements and recommended
El Nahass H, Naiem SN. (2014) Analysis of the
Periodontology 88, 173-180. clinical procedures regarding optimizing esthetic
dimensions of the labial bone wall in the anterior
Buser D, Chappuis V, Belser UC, Chen S. (2017) Implant maxilla: A cone-beam computed tomography study. outcomes in implant dentistry. The International
placement post extraction in esthetic single tooth Clinical Oral Implants Research 26, e57-e61. Journal of Oral and Maxillofacial Implants 29 Suppl,
sites: When immediate, when early, when late? 216-220.
Periodontology 2000 73, 84-102. Hämmerle CH, Araujo MG, Simion M. (2012) Evidence-
based knowledge on the biology and treatment of Noelken R, Oberhansl F, Kunkel M, Wagner W. (2016)
Cardaropoli G, Araújo M, Lindhe J. (2003) Dynamics extraction sockets. Clinical Oral Implants Research Immediately provisionalized OsseoSpeed Profile
of bone tissue formation in tooth extraction sites. 23 Suppl 5, 80-82. implants inserted into extraction sockets: 3-year
An experimental study in dogs. Journal of Clinical results. Clinical Oral Implants Research 27, 744-749.
Periodontology 30, 809-818. Huynh-Ba G, Pjetursson BE, Sanz M, Cecchinato D,
Ferrus J, Lindhe J, Lang NP. (2010) Analysis of the Rungcharassaeng K, Kan JY, Yoshino S, Morimoto
Chappuis V, Engel O, Reyes M, Shahim K, Nolte LP, T, Zimmerman G. (2012) Immediate implant
socket bone wall dimensions in the upper maxilla
Buser D. (2013) Ridge alterations post-extraction in placement and provisionalization with and without
in relation to immediate implant placement. Clinical
the esthetic zone: A 3D analysis with CBCT. Journal a connective tissue graft: An analysis of facial
Oral Implants Research 21, 37-42.
of Dental Research 92 Suppl 12, S195S-S201. gingival tissue thickness. International Journal of
Chappuis V, Araujo, MG, Buser, D. (2017). Clinical Januário AL, Duarte WR, Barriviera M, Mesti JC, Araújo Periodontics and Restorative Dentistry 32, 657-663.
relevance of dimensional bone and soft tissue MG, Lindhe J. (2011) Dimension of the facial bone
wall in the anterior maxilla: A cone-beam computed Sarnachiaro GO, Chu SJ, Sarnachiaro E, Gotta SL,
alterations post-extraction in esthetic sites. Tarnow DP. (2015) Immediate implant placement
Periodontology 2000 73, 73-83. tomography study. Clinical Oral Implants Research
22, 1168- 1171. into extraction sockets with labial plate dehiscence
Chen ST, Beagle J, Jensen SS, Chiapasco M, Darby I. defects: A clinical case series. Clinical Implant
(2009) Consensus statements and recommended Joly JC, de Carvalho PFM, da Silva RC. (2015) Perio- Dentistry and Related Research 18, 821-829.
clinical procedures regarding surgical techniques. Implantodontia Estética. São Paulo: Quintessence.
Sclar AG. (2004) Strategies for management of single-
The International Journal of Oral and Maxillofacial Kan JYK, Rungcharassaeng K, Sclar A, Lozada J. (2007) tooth extraction sites in aesthetic implant therapy.
Implants 24 Suppl, 272-278. Effects of the facial osseous defect morphology Journal of Oral and Maxillofacial Surgery 62 Suppl
Chen ST, Buser D. (2009) Clinical and esthetic outcomes on gingival dynamics after immediate tooth 2, 90-105.
of implants placed in postextraction sites. The replacement and guided bone regeneration: 1-year
International Journal of Oral and Maxillofacial results. Journal of Oral and Maxillofacial Surgery 65, Slagter KW, Meijer HJ, Bakker NA, Vissink A, Raghoebar
Implants 24 Suppl, 186-217. 13-19. GM. (2016) Immediate single-tooth implant
placement in bony defects in the esthetic zone:
Chen ST, Darby I. (2016) The relationship between facial Kan JY, Rungcharassaeng K, Morimoto T, Lozada
A 1-year randomized controlled trial. Journal of
bone wall defects and dimensional alterations of J. (2009) Facial gingival tissue stability after
Periodontology 87, 619-629.
the ridge following flapless tooth extraction in the connective tissue graft with single immediate tooth
anterior maxilla. Clinical Oral Implants Research 28, replacement in the esthetic zone: Consecutive case Su H, González-Martín O, Weisgold A, Lee E. (2010)
931-937. report. Journal of Oral and Maxillofacial Surgery 67 Considerations of implant abutment and crown
Suppl 11, 40-48. contour: Critical contour and subcritical contour.
Clavijo V, Blasi A. (2017) Decision-making process for
International Journal of Periodontics & Restorative
restoring single implants. Quintessence of Dental Kan JYK, Roe P, Rungcharassaeng K, Patel R, Waki T,
Dentistry 30, 335-343.
Technology 40, 66-88. Lozada JL, Zimmerman G. (2011) Classification
Cosyn J, De Bruyn H, Cleymaet R. (2013) Soft of sagittal root position in relation to the anterior Tan WL, Wong TL, Wong MC, Lang NP. (2012) A
tissue preservation and pink aesthetics around maxillary osseous housing for immediate implant systematic review of post-extractional alveolar hard
single immediate implant restorations: A 1-year placement: A cone beam computed tomography and soft tissue dimensional changes in humans.
prospective study. Clinical Implant Dentistry and study. The International Journal of Oral and Clinical Oral Implants Research 23 Suppl 5, 1-21.
Related Research 15, 847-857. Maxillofacial Implants 26, 873-876. Yoshino S, Kan JY, Rungcharassaeng K, Roe P, Lozada
Cosyn J, Eghbali A, Hermans A, Vervaeke S, de Bruyn Kan JYK, Roe P, Rungcharassaeng K, Deflorian M, JL. (2014). Effects of connective tissue grafting on
H, Cleymaet R. (2016) A 5-year prospective study Weinstein T, Wang HL, Testori T. (2018) Immediate the facial gingival level following single immediate
on single immediate implants in the aesthetic zone. implant placement and provisionalization of implant placement and provisionalization in the
Journal of Clinical Periodontology 43, 702-709. maxillary anterior single implants. Periodontology esthetic zone: A 1-year randomized controlled
2000 77, 197-212. prospective study. The International Journal of Oral
Da Rosa JC, da Rosa AC, Francischone CE, Sotto-Maior
and Maxillofacial Implants 29, 432-440.
BS. (2014) Esthetic outcomes and tissue stability Meijer HJA, Slagter KW, Vissink A, Raghoebar, GM.
of implant placement in compromised sockets (2019). Buccal bone thickness at dental implants in Zuiderveld EG, Meijer HJA, den Hartog L, Vissink
following immediate dentoalveolar restoration: the maxillary anterior region with large bony defects A, Raghoebar GM. (2018) Effect of connective
Results of a prospective case series at 58 months at time of immediate implant placement: A 1-year tissue grafting on peri-implant tissue in single
follow-up. International Journal of Periodontics & cohort study. Clinical Implant Dentistry and Related immediate implant sites: A RCT. Journal of Clinical
Restorative Dentistry 34, 199-208. Research 21, 73-79. Periodontology 45, 253-264.
22
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24
Clinical case
IMMEDIATE DENTOALVEOLAR RESTORATION

FOR THE TREATMENT OF TYPE II
AND TYPE III EXTRACTION SOCKETS
USING TRIPLE GRAFT FROM MAXILLARY
TUBEROSITY: A CASE SERIES.
JOSÉ C. MARTINS DA ROSA, ARIÁDENE C. PÉRTILE DE OLIVEIRA ROSA, LUIS A. VIOLÍN DIAS PEREIRA.
José Carlos Martins da Rosa. PhD in Oral

Implantology, São Leopoldo Mandic Dental
Research Center, Campinas, São Paulo, Brazil.
SUMMARY
Introduction
Ariádene Cristina Pértile de Oliveira Rosa. PhD
in Oral Implantology, São Leopoldo Mandic Immediate implant placement in compromised sockets is challenging. The three-
Dental Research Center, Campinas, São Paulo, dimensional implant position, buccal bone wall quality, and regeneration of soft-tissue
Brazil contours are key factors for long-term outcomes. Here, we present three cases in which
Luis Antonio Violín Dias Pereira. Professor of immediate dentoalveolar restoration (IDR) with a triple graft (TG) was used for the
Department of Biochemistry and Tissue Biology, treatment of Type II and Type III extraction sockets. IDR-TG consists of immediate
State University of Campinas (UNICAMP), implantation; harvesting of a single-piece TG comprising connective tissue and cortical
Institute of Biology, Campinas, São Paulo, and cancellous bone from the maxillary tuberosity (MT); and immediate provisionalization
Brazil. in a single procedure.
Case presentation
One case with Type II and two cases with Type III extraction sockets in the maxillary
anterior zone showed bone loss and extremely thin periodontal biotypes. Cases 2 and 3
showed socket infection along with gingival recession. IDR-TG was performed in all cases,
with 5–8 years follow-up to demonstrate the stability of the bone walls and soft-tissue
(gingival margin and papillae) contour.
Discussion
The main advantages of IDR-TG use observed in this case series are the reversal of severe
buccal bone loss, improved gingival thickness, and compensation of gingival recession in
a single procedure, which reduces overall costs and treatment times. These three cases
exemplify the method’s clinical and tomographic effectiveness in the achievement of soft-
and hard-tissue stability in extraction sockets.
Correspondence to: Conclusion

José Carlos Martins da Rosa IDR-TG yielded excellent long-term results in the three cases reported here and should be
josecarlos@rosaodontologia.com.br considered for the treatment of Type III extraction sockets.
25 José C. Martins da Rosa A. C. Pértile de Oliveira Rosa Luis A. Violín Dias Pereira
INTRODUCTION
IMMEDIATE IMPLANT PLACEMENT after condemned tooth extraction may be
challenging due to the presence of bone defects, infection, and/or inflammation. The
preservation or creation of harmonious soft-tissue contours in the peri-implant mucosa
and adequate bone support are the key for the achieving favorable esthetic outcomes after
esthetic-zone implant treatment (Rosa et al. 2009; Huynh-Ba et al. 2010).
Several surgical alternatives for post-extraction bone and soft-tissue augmentation in
compromised sockets have been described (Elian et al. 2007; Cosyn et al. 2011; Schneider
et al. 2011; Buser et al. 2013, 2017; Kan et al. 2018). However, these procedures may
require more than one tissue graft type and/or guided bone regeneration, and they entail
long rehabilitation periods and high costs.
In 2007, Elian et al. proposed a classification of alveolar defects, improved in 2015 by
Chu et al., which were taken into account in this article. Type II, subclassification IIC,
and Type III defects present with a greater degree of difficulty in therapy and should
be approached with caution, especially in the esthetic zone (Elian et al. 2007; Chu et al.
2015). In addition to the effects of bone loss and soft-tissue recession on the treatment of
extraction sockets, we have considered the effects of gingival recession, periapical lesions,
infection, severe bone loss around the condemned tooth, and the periodontal biotype (Rosa
et al. 2019).
In 2006, our group introduced immediate dentoalveolar restoration (IDR), a
regeneration technique used for the treatment of Type II sockets, regardless of bone
defect extent. IDR consists of immediate implant placement with the placement of a
cortico-cancellous block graft harvested from the maxillary tuberosity (MT) (Rosa et al.
2013, 2014d). Tooth extraction and rehabilitation are achieved with this single procedure,
summarized as (Rosa et al. 2013, 2014d):
1. Minimally invasive tooth extraction and socket curettage and cleaning, avoiding
damage to the remaining tissue
2. Flapless surgery at the recipient site with an intrasulcular incision for extraction
3. Implant placement 3 mm apical to the gingival margin (or the cementoenamel junction
of the contralateral tooth in cases of gingival recession), with the selection of an
implant diameter enabling preservation of a 3-mm socket gap (between the implant
and buccal bone wall, or internal surface of the buccal soft tissue when the buccal bone
wall is absent) (Rosa et al. 2016)
4. Implant positioning, primarily by guided surgery, with direction toward the palatine
bone wall to obtain primary stability (insertion torque ≥30 Ncm)
5. Preservation of the alveolar ridge dimensions with a particulate bone graft harvested
from the MT positioned in the 3-mm socket gap (for intact sockets), and a cortico-
cancellous block from the MT as a biological barrier when the bone wall is absent
6. Immediate temporary crown placement and appropriate emergence profile creation
7. Immediate non-occlusal loading (provisionalization).
Postoperatively, patient monitoring every 2 days for the first 2 weeks and every 15
days for the next 3 months is recommended. This protocol yielded satisfactory, predictable
esthetic outcomes in a prospective case series (Rosa et al. 2016). The most challenging
aspects of its technical application are related to accurate socket defect diagnosis and graft
adaptation in the recipient site, as the procedure is flapless. Prototyping may facilitate the
procedure and increase precision (Rosa et al. 2017).
26
José Carlos Martins da Immediate dentoalveolar restoration for the treatment of type II and type III extraction sockets using triple Clinical case
Rosa at al. graft from maxillary tuberosity: a case series
In 2009, our team introduced the use of a triple graft (TG), formed by adding a layer of
connective tissue to the cortico-cancellous block and particulate bone, for IDR. IDR-TG is
indicated for the treatment of Type III sockets with extremely thin periodontal biotypes or
severe buccal bone wall damage in combination with gingival recession (Rosa et al. 2009).
It enables proper implant rehabilitation in a fresh compromised extraction socket with
alveolar bone and soft-tissue defects and provides significant gains in esthetic outcomes,
with gingival architecture maintenance or improvement (Rosa et al. 2014a; Rosa and
Pereira 2019). We describe three cases illustrating the favorable clinical outcomes
achieved with IDR-TG, including long-term gingival topography and bone stability, as
observed by cone-beam computed tomography (CBCT).
CASE 1
1. The patient’s problem
A 33-year-old female presented with a compromised maxillary right central incisor, severe
bone loss, and a thin periodontal biotype.
2. Diagnosis
Clinical inspection revealed an extremely thin gingival biotype (Figure 1) and CBCT
confirmed total buccal bone wall loss, showing a Type IIC alveolar defect (Figure 2).
3. Aim of the treatment

The main treatment aims were to restore the buccal wall and increase gingival thickness.
Figure 1. Figure 2.
Clinical evaluation of case 1 revealed a condemned maxillary right central incisor with total loss of the buccal CBCT confirmed the total loss of the buccal bone
wall and extremely thin periodontal biotype without gingival recession. The periodontal pocket depth was 10 wall in case 1.
mm.
27
4. Treatment plan
Minimally invasive tooth extraction and socket curettage and cleaning were followed by
immediate implant placement in the three-dimensionally (3D) correct position to achieve
primary stability (insertion torque ≥30 Ncm), with a gap of about 3 mm left on the buccal
aspect. A screw-type provisional crown with an ideal critical and subcritical emergence
profile contour, providing space for appropriate graft accommodation, was fabricated.
The buccal bone defect was repaired and soft-tissue thickness was improved using a TG
harvested from the MT (Figures 3, 4, 5, 6 and 7).
For TG harvest, a mucoperiosteal incision was made along the distal contour of the
second molar, approximately 3 mm from its distal aspect. Two vertical mucoperiosteal
Figure 3. releasing incisions were then made in the posterior direction, reproducing the defect
After tooth extraction in case 1, loss of the buccal shape. The donor-site flap was then divided starting at the buccal line angle, with the
wall was confirmed clinically.
blade then directed to the posterior-most portion of the releasing incisions, with retention
of 1–2 mm connective-tissue thickness to cover t¬he bone. A straight IDR chisel (Schwert,
Seitingen-Oberflacht, Germany) was inserted along the releasing incisions to define the
bone fracture line. The chisel was initially positioned perpendicular to the bone structure
on the incision line surrounding the distal part of the second molar. After about 3 mm
insertion with the aid of a surgical hammer, its angulation was changed to parallel the
outer connective-tissue surface (Figure 8). The chisel was deepened gradually to the
distal limit of the releasing incisions to obtain a uniform bone/gingival graft. The bone
was fractured, and an incision was made in the distal portion of the connective tissue
to remove the TG in a single piece, with care taken to maintain an epithelial pedicle to
ensure better nutrition for the donor-site flap. A particulate bone graft was harvested
Figure 4.
from the same area to fill the gap between the marrow portion of the TG and the implant
In case 1, the implant was anchored to the surface. The donor site was then closed with single interrupted 6-0 sutures.
remaining palatal bone in the 3D position To facilitate TG adaptation in the recipient site, which allows for better reconstruction
favoring the construction of the screw-type
provisional crown. As the dimension of the
and accelerates graft incorporation, the graft was shaped to fit the bone and soft-
buccal–palatal socket was 7 mm, a 4-mm-diameter tissue defect. It was inserted between the inner soft tissue and the buccal aspect of the
implant was selected to allow a 3-mm gap on the implant, with maintenance of a biological distance of 1 mm above the level of the implant
buccal aspect.
platform, and ensuring placement of its connective-tissue portion 2 mm above the bone
graft area at the level of the contralateral gingival margin. The TG was stabilized by
suturing its connective-tissue portion to the gingival flap. The residual gaps were filled
with the particulate cancellous bone harvested from the MT. A provisional restoration
was performed. An appropriate anatomical contour of the prosthetic emergence profile,
mandatory to guide soft-tissue healing, was created. The provisional crown was placed
immediately and adjusted out of occlusion. Definitive restoration was performed 3 months
postoperatively (Figures 9 and 10).
5. Prognosis
The patient was followed clinically for 5 years. The soft-tissue contour (gingival margin
and papillae) remained stable (Figure 11).
Figure 5. Figure 6.
The TG (connective tissue, and cortical and cancellous Occlusal view of case 1 showing the 3-mm buccal
bone in a single piece) harvested from the MT was gap filled with the TG and particulate bone graft
placed in the buccal defect site to repair the hard- and harvested from the MT.
soft-tissue damage in case 1.
28
Figure 7.
The triple graft is removed with a straight chisel.
First, the chisel is positioned perpendicular to the
incision line. After a slight deepening with the help
of a hammer, its angle is changed to be parallel to
the soft-tissue surface. Then, the three graft layers
Figure 8. (connective tissue, cortical and spongy bone) can
A screw-type provisional crown with an adequate emergence profile enabling proper tissue accommodation was be seen. Reproduced from Rosa et al. 2014, with
manufactured using the case 1 patient’s crown. authorization.
Figure 9.
The soft tissue had healed and maintained the appropriate position at 3 months postoperatively in case 1.
Figure 10.
Soft-tissue CBCT image of case 1 after 4 months
showing incorporation of the bone graft and
improvement of soft-tissue thickness.
Figure 11.
Stability of the soft-tissue contour, namely the gingival margin and papillae, at 5 years postoperatively in case 1.
29
CASE 2
A 28-year-old male presented with a periodontally compromised maxillary right canine
associated with an abscess, fistula, severe bone loss, gingival recession, and a thin
periodontal biotype (Figure 12).
2. Diagnosis
On clinical inspection, the buccal probing depth was approximately 8 mm. The alveolar
Figure 12.
In case 2, the maxillary right canine had been
defect was Type III. Soft-tissue CBCT confirmed total buccal wall loss beyond the root
lost, with about 2.0 mm gingival recession and a apex of the affected tooth. A 3D image showed the extent of the bone defect. Prototyping
fistula. enabled measurement of the buccal aspect of the defect in the coronoapical and
mesiodistal directions (9 and 7 mm, respectively) (Figure 13).
3. Aim of the treatment

The main treatment aims were to restore the buccal wall, improve gingival thickness, and
compensate the gingival recession.
4. Treatment plan
The patient was prescribed antibiotics for 5 days preoperatively and 7 days
postoperatively due to surgical area contamination. He was treated as described in case 1
(Figures 14, 15, 16, 17 and 18).
5. Prognosis
Figure 13. Clinical evaluation at 6 years postoperatively showed stability of the soft-tissue volume,
3D prototyping showed the buccal bone wall gingival margin, and papillae positioning (Figure 19). CBCT showed complete restoration
defect in case 2; total loss of the buccal bone wall
of the buccal bone wall (Figure 20).
beyond the limits of the root can be seen.
Figure 14.
After tooth extraction in case 2, the soft tissue
was collapsed due to the absence of the buccal
bone wall.
Figure 15. Figure 16.

In case 2, the TG harvested from the MT was Occlusal view of case 2 showing the 3 mm gap filled with the TG and cancellous particulate bone graft harvested
inserted into the buccal defect site to repair hard- from the MT.
and soft-tissue damage, after implant insertion
and particulate bone filling.
30

A screw-type provisional crown with an emergence profile enabling proper TG accommodation was inserted The soft tissue had healed and maintained the
in case 2. Two millimeters of the connective tissue of the TG was left exposed to improve the coronal gingival appropriate position at 3 months postoperatively.
margin. This tissue was sutured using 6-0 mononylon.

Case 2 showed stability of the soft tissue at 6 years postoperatively. CBCT performed 6 years postoperatively in case 2
revealed stability of the buccal wall thickness and
height.
31
CASE 3
A 49-year-old male presented with a compromised maxillary right central incisor
associated with severe bone loss, an abscess, fistula, gingival recession, and an extremely
thin periodontal biotype.
2. Diagnosis
On clinical inspection, the buccal probing depth was approximately 10 mm (Figure 21).
Figure 21. CBCT confirmed total buccal bone wall loss beyond the root apex of the affected tooth
In case 3, the maxillary right central incisor
region showed about 3.0 mm gingival recession, (Figure 22).
the presence of an abscess, and poor soft-tissue
quality. 3. Aim of the treatment
The main treatment aims were to restore the buccal bone wall, improve gingival
thickness, and compensate the gingival recession.
4. Treatment plan
The patient was treated as in cases 1 and 2, with the following differences. Given the
degree of gingival recession, four incisions were made in the gingival papillae area;
two horizontal incisions in the area corresponding to the cementoenamel junction of
the adjacent tooth, followed by two divergent incisions corresponding to the gingival
recession pattern for coronal repositioning of the gingival tissue (Figures 23 and 24). The
connective-tissue portion of the graft was then stabilized up to the level of the repositioned
gingival margin (Figures 25, 26 and 27), as appropriate in such cases with 3–4 mm
gingival recession. Other aspects of graft and provisional crown placement were as
described for case 1 (Figure 28). After 3 months, a final ceramic crown was fabricated and
placed (Figure 29).
5. Prognosis
Clinical evaluation at 8 years postoperatively showed soft-tissue (gingival margin and
papillae) stability and maintenance of the anatomical contour of the gingival architecture
(Figure 30). CBCT showed complete restoration of the buccal bone wall (Figure 31).
Figure 22.
CBCT showed total absence of the buccal bone
wall in case 3.
Figure 23.
In case 3, the soft tissue had collapsed after tooth
extraction due to the absence of the buccal bone
wall.
Figure 24.
The implant was installed with palatine anchoring in case 3. Four small incisions in the gingival papillae area
were performed: two horizontal incisions, followed by two divergent incisions corresponding to the gingival
recession pattern. The pedicles between the two incisions were removed. 32

In case 3, the TG was harvested from the MT using a The TG in case 3 was remodeled according to the
chisel. defect shape and size.

It was positioned in the recipient site with the A screw-type provisional crown with an emergence The soft tissue had healed and maintained its
connective tissue portion turned to the gingival profile that enabled TG accommodation inserted in case appropriate position, with remarkable volume on
mucosa and the cancellous bone portion turned to 3. The graft was stabilized by suturing of its connective the buccal aspect, at 3 months postoperatively in
the implant. The gap was filled with the particulate tissue portion to the gingival flap in the recipient area. case 3.
bone graft. Simple sutures were placed in the mesial and distal
papillae regions.

Case 3 showed stability of the soft-tissue contour (gingival margin and papillae positions) at 8 years CBCT perfomed 8 years postoperatively in case
postoperatively. 3 revealed stability of the buccal bone wall
33 thickness and height.
DISCUSSION
NUMEROUS SURGICAL PROCEDURES FOR EXTRACTION SOCKET TREATMENT
with immediate implant placement have been described (Elian et al. 2007; Cosyn et al.
2011; Schneider et al. 2011; Buser et al. 2013, 2017; Kan et al. 2018). Surgical access to
extraction sockets has been obtained with full flaps (Waki and Kan 2016) and no flap
(Frizzera et al. 2019). To address buccal bone-plate deficiency and fill residual defects,
autogenous bone chip grafts (Noelken et al. 2011), particulate deproteinized bovine bone
mineral (DBBM) with and without autogenous bone (Kan et al. 2007; Tripodakis et al.
2016), platelet concentrates with allogeneic mineral bone (Norero and Ibanez 2018),
DBBM mini-blocks with collagen (Albiero et al. 2014; Assaf et al. 2017), and bovine bone
mineral containing 10% porcine collagen placed between the membrane and dental
implant with a soft-tissue graft (Fizzera et al. 2019) have been used. All graft types yield
satisfactory esthetic results, with some limitations.
IDR is minimally invasive, performed with autogenous bone and soft-tissue grafts
harvested from a single site; the lack of xenogeneic or allogeneic graft or membrane
requirement reduces the overall treatment cost and the possibility of infection or rejection.
It has been shown clinically and tomographically to effectively achieve soft-tissue and
bone stability, thereby re-establishing long-term esthetics and function for Types II and
III extraction sockets (Rosa et al. 2014c, 2016).
The TG from the MT is ideal for bone and soft-tissue regeneration, as it provides a
natural scaffold filled with cells and growth factors. For this reason, IDR-TG is considered
to be a form of tissue transplantation (Rosa et al. 2013; Martins Jr. et al. 2017; Montanaro
et al. 2019). The long-term success of IDR can be attributed in part to the MT graft’s
structural and biological characteristics, and proper manipulation and adaptation to the
recipient site (Rosa et al. 2014a, 2014b, 2016, 2018).
CONCLUSIONS
CLINICALLY AND TOMOGRAPHICALLY, IDR-TG provided hard- and soft-tissue
gains, with satisfactory esthetic and functional outcomes, in cases with Types IIC and
III extraction sockets. The use of a single-piece TG harvested from the MT should be
considered for alveolar ridge preservation and reconstruction, as it allows for soft- and
hard-tissue integration with a single approach. IDR-TG is a feasible, low-cost solution
that minimizes soft- and hard-tissue collapse and dimensional loss following single-rooted
tooth extraction. Even though it is a sensitive technique and requires experience and
training, when properly indicated and performed, this approach has a high success rate.
CLINICAL RELEVANCE
IN CLINICAL CASES CHARACTERIZED BY TYPE IIC with thin periodontal
biotype, and Type III extraction sockets with thin or thick periodontal biotypes
in combination with ≤4 mm gingival recession or infection, the use of IDR with a
TG harvested from the MT for the regeneration of hard- and soft-tissue damage
in the extraction socket yields clinically and tomographically satisfactory long-
term outcomes. When indicated, tissue transplant with a TG (a single piece
composed of connective tissue and cortical and cancellous bone) improves graft
vascularization and the recovery of gingival recession and bone loss.
34
Albiero AM, Benato R, Degidi M. (2014) Buccal plate Kan JYK, Rungcharassaeng K, Deflorian M, Weinstein Rosa JCM, Rosa ACPO, Zardo CM, Rosa DM, Adolfi
regeneration with immediate postextraction T, Wang HL, Testori T. (2018) Immediate implant D, Canullo L. (2014d) Immediate Dentoalveolar
implant placement and restoration: Case reports. placement and provisionalization of maxillary Restoration: Immediate-loaded implants in
International Journal of Periodontics & Restorative anterior single implants. Periodontology 2000 77, compromised alveolar sockets. Chicago:
Dentistry 34, e67-e72. 197-212. Quintessence Publishing.
Assaf JH, Assaf DD, Antoniazzi RP, Osorio LB, Franca Martins Junior W, Ferraz EP, Beloti MM, Rosa AL, Rosa Rosa ACPO, Rosa JCM, Pereira LAVD, Francischone
FM. (2017) Correction of buccal dehiscence during JCM. (2017) Immediate Dentoalveolar Restoration CE, Sotto-Maior BS. (2016) Guidelines for selecting
immediate implant placement using the flapless technique (IDR). Autograft characterization and a the implant diameter during immediate implant
technique: A tomographic evaluation. Journal of case Report. Journal of Osseointegration 9, 305- placement of a fresh extraction socket: A case
Periodontology 88, 173-180. 309. series. The International Journal of Periodontics &
Buser D, Chappuis V, Bornstein MM, Wittneben JG, Frei Restorative Dentistry 36, 401-407.
Montanaro N, Rosa JCM, Pereira LAV, Romanos
M, Belser UC. (2013) Long-term stability of contour GE. (2019) Role of the maxillary tuberosity in Rosa JCM, Fadanelli MA, Zimmerman D, Rosa ACPO.
augmentation with early implant placement periodontology and implant dentistry - a review. (2017) The application of rapid prototyping
following single tooth extraction in the esthetic Stomatology Edu Journal 6, 249-259. to improve bone reconstruction in immediate
zone: A prospective, cross-sectional study in 41 dentoalveolar restoration: A case report. The
patients with a 5-to 9-year follow-up. Journal of Noelken R, Kunkel M, Wagner W. (2011) Immediate
International Journal of Esthetic Dentistry 12, 258-
Periodontology 84, 1517-1527. implant placement and provisionalization after long-
270.
axis root fracture and complete loss of the facial
Buser D, Chappuis V, Belser UC, Chen S. (2017) Implant bony lamella. International Journal of Periodontics & Rosa JCM, Romanelli J, Calichio LE. (2018)
placement post extraction in esthetic single tooth Restorative Dentistry 31, 175-183. Multidisciplinary approach using slow orthodontic
sites: When immediate, when early, when late? extrusion and the Immediate Dentoalveolar
Periodontology 2000 73, 84-102. Norero HN, Ibáñez MA. (2018) A new technique for
Restoration technique. Quintessence of Dental
rebuilding the buccal plate during placement of
Chu SJ, Sarnachiaro GO, Hochman MN, Tarnow DP. Technology 41, 189-203.
immediate dental implants in an extraction site
(2015) Subclassification and clinical management Rosa JCM, Pereira LAVD. (2019) Predictable esthetic
with buccal defects. Journal of Implant & Advanced
of extraction sockets with labial dentoalveolar anterior maxillary reconstruction with dental
Clinical Dentistry 10, 6-15.
dehiscence defects. Compendium of Continuing implants and maxillary tuberosity grafts. En: Nevins
Education in Dentistry 36, 516-522. Rosa JCM, Rosa DM, Zardo CM, Rosa, ACPO, Canullo M, Wang H-L, organizadores. Implant Therapy:
L. (2009). Reconstruction of damaged fresh sockets clinical approaches and evidence of success. 2.ª ed.
Cosyn J, Eghbali A, De Bruyn H, Collys K, Cleymaet R,
by connective-bone sliver graft from the maxillary Chicago: Quintessence Publishing, v. 1, pag. 175-
De Rouck T. (2011) Immediate single-tooth implants
tuberosity, to enable immediate dentoalveolar 196.
in the anterior maxilla: 3-year results of a case series
restoration (IDR) - a clinical case. Implants 10, 12-17.
on hard and soft tissue response and aesthetics. Rosa JCM, Rosa ACPO, Huwais S. (2019) Use of the
Journal of Clinical Periodontology 38, 746-753. Rosa JCM, Rosa ACPO, Rosa DM, Zardo CM. Immediate Dentoalveolar Restoration Technique
Elian N, Cho S-C, Froum S, Smith RB, Tarnow DP. (2013) Immediate Dentoalveolar Restoration of combined with osseodensification in periodontally
(2007) A simplified socket classification and compromised sockets: A novel technique. The compromised extraction sites. The International
repair technique. Practical Procedures & Aesthetic European Journal of Esthetic Dentistry 8, 432-443. Journal of Periodontics & Restorative Dentistry 39,
Dentistry 19, 99-104. Rosa JCM, Rosa ACPO, Fadanelli MA, Sotto-Maior 527-534.
Frizzera F, Freitas RM, Muñoz-Chávez OF, Cabral G, BS. (2014a) Immediate implant placement, Schneider D, Grunder U, Ender A, Hämmerle CHF, Jung
Shibli JA, Marcantonio Jr E. (2019) Impact of soft reconstruction of compromised sockets, and repair RE. (2011) Volume gain and stability of peri-implant
tissue grafts to reduce peri-implant alterations after of gingival recession with a triple graft from the tissue following bone and soft tissue augmentation:
immediate implant placement and provisionalization maxillary tuberosity: A variation of the immediate 1-year results from a prospective cohort study.
in compromised sockets. International Journal of dentoalveolar restoration technique. The Journal of Clinical Oral Implants Research 22, 28-37.
Periodontics & Restorative Dentistry 39, 381-389. Prosthetic Dentistry 112, 717-722.
Tripodakis AP, Gousias H, Mastoris M, Likouresis
Huynh-Ba G, Pjetursson BE, Sanz M, Cecchinato D, Rosa JCM, Rosa ACPO, Francischone CE, Sotto-Maior D. (2016) Five-year volumetric evaluation of
Ferrus J, Lindhe J, Lang NP. (2010) Analysis of the BS. (2014b) Diameter selection of implants placed periodontally compromised sites restored by
socket bone wall dimensions in the upper maxilla in extraction sockets: A new approach. Dental Press immediate implant restorations. International
in relation to immediate implant placement. Clinical Implantology 8, 80-89. Journal of Periodontics & Restorative Dentistry 36,
Oral Implants Research 21, 37-42. Rosa JCM, Rosa ACPO, Francischone CE, Sotto-Maior 645-653.
Kan JY, Rungcharassaeng K, Sclar A, Lozada JL. (2007) BS. (2014c) Esthetic outcomes and tissue stability Waki T, Kan JYK. (2016) Immediate placement and
Effects of the facial osseous defect morphology of implant placement in compromised sockets provisionalization of maxillary anterior single implant
on gingival dynamics after immediate tooth following immediate dentoalveolar restoration: with guided bone regeneration, connective tissue
replacement and guided bone regeneration: 1-year results of a prospective case series at 58 months graft, and coronally positioned flap procedures.
results. Journal of Oral and Maxillofacial Surgery 65, follow-up. The International Journal of Periodontics International Journal of Esthetic Dentistry 11, 174-
13-19. & Restorative Dentistry 34, 199-208. 185.
35
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Clinical case
TRIMODAL APPROACH:
“THE PREDICTABLE,
THE PLAUSIBLE,
AND THE IMPONDERABLE”.
GUSTAVO CABELLO, DAVID GONZÁLEZ, JUAN ZUFÍA, JUAN MESQUIDA.
Gustavo Cabello. Master’s degree

in periodontology and specialist in
osteointegration from the UCM. Exclusive
SUMMARY
practice in periodontology, implantology, and
IMMEDIATE IMPLANTS in flapless surgical procedures and with immediate
prosthodontics in Malaga.
provisionalization (trimodal approach, TA) represent a very advantageous clinical
David González. Doctor in dentistry. Master’s
approach in terms of reducing the sequence of treatment, patient acceptance (a single
degree in periodontology and specialist in
osteointegration from the UCM. Exclusive
surgical intervention after which an aesthetic, stable, and immediate provisionalization
practice in periodontology and implantology can be achieved), and the optimization of the aesthetic results (through the effect of the
in Murcia. provisional whether or not combined with actions on the behaviour of the soft tissue and
Juan Zufía. Periodontology and prosthodontics, the bone gap). For these reasons, its use has expanded, and it has been documented as
Doctor of Dental Medicine, PhD. Private predictable when certain clinical circumstances are given. Nonetheless, the effects of
practice in Madrid. actions in the bone compartment (gap filling) and the mucosal behaviour (implementation
Juan Mesquida. Periodontology and of an envelope connective-tissue graft) on the outcome, as well as which factors are
prosthodontics, Doctor of Dental Medicine, more decisive in terms of the emergence profile of the provisional, have still not been
master’s degree in implantology from the
discerned. The article will focus on three possible technical approaches starting from
University of Loma Linda, CA, USA. Assistant
professor in the Department of Implantology, an original proposal in which no action is taken on these compartments (TA), compared
University of Loma Lina, CA, USA. Private with alternatives that introduce gap filling (TAB) or gap filling together with an envelope
practice in Mallorca. connective-tissue graft (TABM). Furthermore, new lines of research will be introduced
in those situations in which techniques today lack a solid scientific support, such as
Correspondence to: situations in which there are alterations of the anatomy of the alveolar socket, whether
Gustavo Cabello exclusively in its bone component (type II sockets) or in its bone and mucosal components
info@clinicanexus.com (type III sockets).
39 Gustavo Cabello David González Juan Zufía Juan Mesquida

INTRODUCTION
A SCIENTIFIC PARADIGM is a common ideal of explication, a theoretical model, and
a series of methods to solve problems in the training of researchers and it constitutes
the framework within whose precepts scientific activity is developed at a given moment.
In the evolution of science, periods can be distinguished marked by the acceptance of a
paradigm and periods of revolution in which there are paradigms in competition. Even
through “evidence-based dentistry” (as a subcategory within the biological sciences) has
been based on contributions derived from the statistical methods – especially linked
to clinical trials – it is important not to forget that this approach (of consubstantial
revisionist accent) would not be possible without a “primordial phase of creative
ingenuity” that allows the conception of new hypotheses. Thus, in the advance of
science, the revisionism that is the fruit of the statistical method is as important as the
intellectual creativity that gives birth to new hypotheses. Both phases are relevant to each
other and nurture each other, even though the creative aspect may be unjustly relegated
to a secondary plane at the academic level.
Based on this initial idea and considering the update that we provide in this article, we
have tried to approach this subject developing not only the typical literature review with
a view to describing the current state of the question in relation to the trimodal approach
(TA, immediate implant in flapless protocol and with immediate provisionalization)
(Figure 1), but also opening new possible clinical horizons. In accordance with this
approach, we have created three sections in our article which, breaking down the subject,
focus on “the predictable, the plausible, and the imponderable”, strategies that will be
debated for single implants and in accordance with the integrity of the alveolar socket,
using for this purpose the classification by Elian et al. (2007), which distinguishes the
following types:
- Type I alveoli: with integrity of the alveolar ridge and the soft tissue.
- Type II alveoli: with retraction of the alveolar ridge but with ideal positioning of the
soft tissue.
- Type III alveoli: with recession of both the tissue of the alveolar ridge and the soft-
tissue margin (Figure 2).
Figure 2. Figure 1.
Classification of the types of alveoli. Reproduced Correct position of the implant in the post-extraction alveolar socket for the technique of immediate implant
with permission from Elian et al. (2007). with immediate provisional in the flapless protocol (trimodal approach).
40
Gustavo Cabello et al. Trimodal approach: “the predictable, the plausible, and the imponderable” Clinical case
DEVELOPMENT
THE PREDICTABLE. TYPE I ALVEOLI
SOMETHING IS CONSIDERED “PREDICTABLE” when its outcome can be predicted
before the execution of a test. In medical sciences, this idea is associated with therapeutic
acts covered by the “scientific evidence”, although we prefer not to use this term because
at the epistemological level only the axioms are evident and in clinical approaches there
is always a certain degree of uncertainty that could lead to the falsification of the proposal
based on an inductive methodology (the observation of particular cases from which a
universal law can be induced).
We thus consider that TA is a predictable technique in type I alveoli, after having
analysed the published literature on the topic – above all that of the last two decades –
whose most relevant facts we describe below.
In the first decade of the new millennium, a series of articles concluded that after
tooth extraction a series of biological processes is triggered that affect the architecture
of the alveolar ridge, which leads to a recession and a collapse of the dental ridge (Chen
et al. 2004). However, the survival rate of implants placed immediately post-extraction
have been shown to be very similar to those of implants placed in cicatrized bone (Bianchi
and Sanfilippo 2004; Norton 2004; Lang et al. 2007; Quirynen et al. 2007). Other studies
concluded that the insertion of a dental implant into the post-extraction alveolar socket did
not modify the physiological remodelling that is produced in the empty socket (Schropp et
al. 2003; Araújo et al. 2005, 2006a, 2006b; Cardaropoli et al. 2007; Vignoletti et al. 2009).
Because of this, the “paradigm” came to be accepted that the coronal portion of the alveolar
bone (known as bundle bone) was a part of the periodontium dependent on the stimulus of
the periodontal ligament, which atrophies once the tooth is extracted from its bed, triggering
an average retraction of soft tissue of between 0.5 and 1 mm (Araújo et al. 2005, 2006a,
2006b). This “paradigm” became so categorical for certain schools that immediate implants
post-extraction in the anterior sector (the aesthetic area) were rejected as a reasonable
treatment option and the systematic use of clinical approaches based on deferred implants
was recommended (Belser et al. 2004, 2009).
Despite these biological handicaps, immediate implants offered benefits derived from
the possibility of avoiding two surgical acts and from the reduction of treatment time,
which is seen as particularly attractive as in the surgical procedure itself the patient could
receive an immediate implant-supported provisional. Immediate provisionalization from
a biological point of view results in the maintenance of an interproximal sulcus because
of the anatomical support provided by the restorative material (Vacek et al. 1994), in
comparison with implants placed according to the classical protocol (Chang et al. 1999).
For all that, factors that could influence the contour of the buccal soft tissue when placing
immediate implants were started to be analysed to thereby improve the results of this
technique. Some of these factors were the dimensions of the periodontal biotype/phenotype
and the three-dimensional position of the implant (Buser et al. 2004; Chen et al. 2004, 2007;
Evans and Chen 2008), flapless approaches versus those with a flap (Fickl et al. 2008a;
Blanco et al. 2008), the distance of the neck of the implant from the most coronal buccal
plate (Paolantonio et al. 2001; Bottticelli et al. 2003b), whether or not the gap between the
implant and the bone ridge is filled with a bone graft (Chen et al. 2007; Juodzbalys and
Wang 2007; Araújo et al. 2009), the use of an immediate implant-supported provisional
(Chausu et al. 2001; Groisman et al. 2003; Kan et al. 2003; Atieh et al. 2009; Cabello et al.
2013); and the simultaneous use of an envelope connective-tissue graft (Kan et al. 2009;
Chen 2009). All these questions seem to influence the outcome of this technique, and most
research seems to place a capital importance on the fact that the dental socket is intact for
this type of approach (type I alveoli, according to the cited classification).
41
In those cases where an adequate primary stability of the implant was achieved, the
provisional restoration provided a plus in terms of patient acceptance and this approach –
defined by Atieh et al. (2009) as the bimodal approach – implied the use of an immediate
provisional implant in flap approaches. However, it was observed that the procedure defined
by this author was associated with a considerable risk of non-optimal results (aesthetically
unfavourable because of tissue recession). Because of this –and taking into account the
reduction of the crestal resorption and the resulting recession of the marginal soft tissue
Figure 3.1. which seems to result from flapless procedures – Atieh’s original denomination was modified
The establishment of a first gap between the and defined as the trimodal approach (TA) (Cabello et al. 2013), a strategy in which a
implant and the alveolar socket and a second
procedure was added that used an immediate implant and an immediate provisional, but in
gap between the healing abutment (or a non-
anatomical restoration) and the soft tissue can a flapless procedure.
generate a colonization of this space by the cells In a case series, Cabello et al. (2013) analysed the result of this approach in 14 patients
of the kinetically most rapid tissue (epithelial in whom single implants had been placed in the aesthetic zone, investigating the effect of
and connective), which results in a loss of the
the biotype/phenotype on the clinical result. The study analysed the results of the TA, where
architecture of the peri-implant tissues.
neither filling of the bone gap nor overcontouring of the soft tissue with a connective graft
was carried out. The case series revealed an average recession of 0.45mm (±0.25 mm) at 12
months, an adequate papillae architecture, and no correlation could be established between
the recession of the soft tissue and the gingival biotype. These results coincided with the
previous case series of other authors (Kan et al. 2003; De Rouck et al. 2008; Palattella et al.
2008). In the current article, the authors propose a hypothesis around the determining role
of the provisional restoration which, developed with an anatomical contour that copies the
profile of the extracted tooth, acts as a “contact inhibitor” that excludes tissues with more
rapid tissue kinetics (epithelial and connective), through a phenomenon the authors name
“restorative tissue inhibition”, as documented in Figures 3.1 and 3.2.
With the intention of reducing peri-implant remodelling, Araújo et al. (2011) – in a
Figure 3.2. study of immediate implants in five beagle dogs – concluded that filling the bone gap with
The use of an anatomically contoured provisional a biomaterial significantly reduced the resorption of the bone ridge. This observation
promotes a phenomenon of inhibition by contact obtained from the animal model was corroborated in a clinical model in an analysis with
that excludes the most rapid cells (epithelial and
connective) and promotes an optimal and guided
cone-beam computerized tomography (CBCT) of a sample of 21 patients by Roe et al. (2012).
bone and soft-tissue healing (restorative tissue The conceptualization of this clinical variant will be addressed more rigorously in another
inhibition), resulting in an optimal aesthetic section.
result. Other authors, analysing the behaviour of the soft tissue, widened the approach on
observing that the use of an envelope connective-tissue graft in this type of approach –
combined with filling the gap with a bone graft – allowed the maximization of the aesthetic
result by completely containing the recession of the gingival margin (Cornelini et al. 2008;
Kan et al. 2009; Chen 2009; Yoshino et al. 2014). As with gap filing with a bone graft, the
effect of using an envelope connective-tissue graft will be dealt with in another section of
this article.
With these precedents, Cabello et al. (2015) proposed three possible variants of the TA
technique, which was then assigned for intact alveoli (Elian type I), which were named in
the following way:
- Conventional TA (Figure 4.1).
- TA with modification of the bone compartment (filling bone gap with a biomaterial): TAB
(Figure 5.1).
- TA with modification of the bone and mucosal compartments, after filling the gap with a
biomaterial and adding an envelope connective-tissue graft: TABM (Figure 6.1).
1. Trimodal approach (TA): conventional protocol

Linked to the literature review which opened this article, we share below a clinical case in
which this approach was employed (Figure 4).
The technique is used to replace a superior canine with a horizontal fracture that
implies an inadequate dental remnant (ferrule) (Sorensen and Engelman 1990; Libman and
Nichols 1995) to be able to restore the tooth. We have included this case even though neither
the implant (tissue-level implant type) nor the restoration (metal-ceramic) follows the
current therapeutic logic, so that it serves as a reflection for the reader on the evolution of
how this type of case has been approached. This case was carried out in 2008 and continues
to be stable today at both the clinical (absence of tissue recession) and mechanical (stability
of the prosthetic joints) levels. It is noteworthy that, even though there was no filling of the
bone gap, nor overcontouring of the soft tissue with a connective-tissue graft, the aesthetic
result in relation to the gingival margin was optimal, which can be attributed solely to
“restorative tissue inhibition” (Cabello et al. 2013) mediated by the anatomically contoured
provisional.
42
Figure 4.1.
Trimodal approach (TA) using a bone-level implant and an anatomical provisional that reproduces the contour of
the extracted tooth.
Figure 4.3.
Use of the Benex® extractor for the extraction of
the root remnant.
Figure 4.2. Figure 4.4.

Detail of the fractured tooth. Image of the extracted root that precedes the inspection
of the anatomy of the bone bed to confirm the optimal
situation for performing the surgical technique.
Figure 4.5. Figure 4.6. Figure 4.7.

Alveolar socket and gingival tissue intact after the TE® SLActive implant before its insertion in the Implant inserted with it’s carrier.
43 extraction. prepared bed.

Provisional in situ after the TA procedure. Provisional restoration after three months of healing. Customized impression abutment using the profile of
the provisional crown.

Buccal appearance of the peri-implant tissues Definitive restoration. Occlusal view of the appearance of the soft
after the insertion of the titanium abutment tissue after removal of the crown 8 years after its
(SynOcta® abutment). placement.
Figure 4.13.
Appearance of the crown at 8 years (before maintenance appointment).
44
2. Trimodal approach with modification of the bone department (TAB)

One of the main questions in relation to the treatment of post-extraction alveolar sockets
lies in the quantitative definition of the horizontal distance required between the implant
surface and the adjacent alveolar walls, particularly their buccal aspect. It has been
postulated that when the observed space is greater than 1.5 mm, the union between the
implant and the adjacent tissues is of a connective nature in its most coronal portion.
Some authors have suggested that the distance should be less than 0.5 mm (Carlsson
et al. 1988; Knox et al. 1991; Akimoto et al. 1999; Botticelli et al. 2003a; Botticelli et al.
2003b).
In 1998, Wöhrle described for the first time the technique of placing a post-extraction
implant simultaneously with the provisionalization free of occlusal loading (Wöhrle 1998).
In a sample of 14 patients, with a short-term follow-up, the author of this study reported a
survival rate comparable to that of implants placed using a protocol of one or two surgical
phases. The diameter of the implants used in this study is 5-6 mm for all the patients
evaluated, following the clinical recommendations taken from the previously cited studies
(Carlsson et al. 1988; Knox et al. 1991). It is important to emphasize that the information
gained by these studies is generated in preclinical models in which the peri-implant
bone defect is created intentionally in edentulous ridges, something which is difficult to
extrapolate from a histological point of view to the post-extraction alveolar socket (Araújo
et al. 2005).
The use of the technique proposed by Wöhrle was later studied, with successful short-
term biological, mechanical, and aesthetic results (Kan et al. 2003; De Rouck et al. 2008;
Palattella et al. 2008; Evans et al. 2008; Cabello et al. 2013). However, medium- and
long-term studies (Kan et al. 2011a) and systematic reviews (Chen et al. 2009) showed
instability in the position of the buccal peri-implant gingival margin, with its consequent
unfavourable aesthetic impact. In this respect, and even though initially the clinical
proposals backed the use of wide implants that limited the size of the gap, the tendency of
this approach to increase the risk of recession of the gingival margin has meant that today
the use of implants of a smaller diameter is encouraged along with filing the gap with a
bone graft.
Anterior teeth often present a very thin buccal bone and, as a result, a high risk of
resorption associated with extraction and immediate implant placement (Nowzari et
al. 2012), for which the palatal placement of the implant has been recommended with
the intention of leaving a residual buccal space and to be able to avoid the previously
mentioned problem (Kan et al. 2011b). In the literature, we find various studies that
analyse how to treat the residual space between the alveolar walls and the implant
surface in the case of post-extraction implants. In pre-clinical models, it has been observed
that only four months after dental extraction spontaneous bone formation is evident when
the remaining space is of 1-1.25 mm (Botticelli et al. 2003b).
In clinical models, the scientific evidence is limited. Paolantonio et al. (2001) reported
a bone-to-implant contact (BIC) of around 70% in the mandible and of 64.9% in the
superior maxilla, similar to that published for edentulous ridges. In certain samples,
the authors of this publication observed connective tissue in the most coronal part of
the implant, although only in a small number of cases. Cornelini et al. (2000) quantified
the BIC around 61.4%. These authors also quantified the appearance of a supracrestal
band of connective tissue of an average 3.2 mm. Other research, by the group of Wilson
et al. (1988), in a clinical model, observed BIC of 50% with a space between the implant
and the buccal wall of 1.5 mm. A reduction in the BIC was also registered when this
space approached 4 mm. The degree of post-extraction resorption observed is not a direct
consequence of the placement of an immediate implant per se; however, it is directly
related to the apicocoronal and buccolingual placement of the implant (Kan et al. 2011b).
Study models in humans have shown that the use of demineralized allografts, or
other alloplastic materials, is associated with the residual encapsulation of granules in
connective tissue or immature bone after a period of six to nine months (Artzi et al. 2000;
Froum et al. 2002; Carmagnola et al. 2003).
45
On the other hand, the use of bovine xenografts has also been studied in animal
study models of post-extraction implants, in which osteoconductive properties and bone
neoformation have been observed (Berglundh and Lindhe 1997). Artzi et al. (2000) studied
the behaviour of deproteinized bovine xenografts in 15 post-extraction alveolar sockets in
human patients, after biopsies of the attachments together with the adjacent peri-implant
hard tissue nine months after treatment. The authors of this study could observe the
preservation of alveolar bone and the partial maintenance of the architecture prior to the
extraction. The use of bovine grafts has also been evaluated through the acquisition of
tomographic slices with CBCT 30 and 90 days after implant placement, with the aim of
quantifying the resorption of the buccal alveolar bone, of a fasciculate nature. The authors
of this study observed around 20% reduction in post-extraction resorption in cases where
bovine xenograft was used (Nevins et al. 2006).
Araújo et al. (2011), in a study of immediate implants in five beagle dogs, concluded
that filling the bone gap with a biomaterial, simultaneous with reducing the diameter
of the implant, significantly reduced the resorption of the bone ridge. This observation
was corroborated clinically by Roe et al. (2012) in a retrospective analysis with CBCT
on a sample of 21 patients which concluded that a correct selection of the diameter of
the fixation together with the filling of the remaining space with an osteoconductive
biomaterial guarantees the dimensional stability of the peri-implant bone tissue. These
findings have been confirmed recently in a comparative study by Yuenyongorarn et al.
(2020), which analysed prospectively and comparatively the aesthetic result of filling
the space between the implant and the alveolar walls. The results of this study indicate
a greater stability in the buccal peri-implant mucosa, both from the horizontal and
the vertical points of view in the test group, in which the space was filled with bovine
xenograft, compared with the control group in which this space was not grafted with any
biomaterial. Despite this, the retraction of the tissue in both groups was significantly
greater than that observed in previous studies, which could be associated with questions
related to the experience of the operators, who in this case were postgraduate students.
Below we present a clinical case alluding to the TAB approach (Figure 5).
A 50-year-old woman, sent by her orthodontist after completion of treatment to
replace both lateral primary incisors with implant-supported crowns. We show the final
Figure 5.1. appearance of both crowns, as well as their 10-year follow-up.
Illustration of the TA protocol with modification of
the bone compartment after filling the gap with a
bone graft (TAB).
Figure 5.2.
Frontal appearance of the dentition in the final part
of the patient’s orthodontic treatment.

After the extraction of both primary incisors, two View of the superior incisors after removal of the orthodontic devices and before performing the surgical
3.3 x 12 Straumann Bone Level® implants were treatment.
inserted and two provisional titanium abutments
were screwed onto these on which the provisional
crowns were placed.
46

Appearance of the provisional crowns where an Detail of the insertion of the xenograft (Bio-Oss® View of the provisional crowns once screwed
anatomical profile is established to encourage the Geistlich) in the bone gap of both incisors. and freed of occlusal contacts at maximum
appropriate “restorative tissue inhibition”. intercuspation, protrusive, and lateral contacts.

Occlusal view of the tissue remodelling obtained with Frontal appearance after the removal of the
provisional restorations three months after surgery provisional crowns and before taking the impression.
and before taking the impression.
Figure 5.13.
Radiological appearance of the implant-supported
crown of 12i after 10 years of functioning.

Definitive zirconium-ceramic crowns (Cares® Appearance of the definitive crowns after their
Straumann abutments) to be screwed directly on insertion.
both implants. The transfer of the profile of the
provisional crowns guarantees profiles of gentle
emergence and compatible with adequate tissue
support.
Figure 5.14.
Figure 5.12. Radiological appearance of the implant-supported
47 Recent clinical appearance of the crowns after 10 years of functioning. crown of 22i after 10 years of functioning.
3. Trimodal approach with modification of the bone and mucosal compartments (TABM)
Several authors have evaluated the effect of the biotype on maintaining the buccal peri-
implant margin and on the height and stability of the interproximal tissues.
Most studies with short follow-ups show a clinically acceptable initial stability of
the peri-implant buccal tissue, independently of the gingival thickness or its phenotype
characteristics (Kan et al. 2003; De Rouck et al. 2008; Palattella et al. 2008; Evans and
Chen 2008).
From the point of view of the stability of the buccal peri-implant mucosa, it has been
observed in medium-term studies that a thick biotype presents a low incidence of buccal
recession, for which a modification of the mucosal compartment (connective tissue graft
or substitute biomaterials) would not be necessary in patients with this phenotypical
profile (Kan et al. 2011b). Nonetheless, longitudinal studies with longer follow-up periods
have observed a greater instability in the peri-implant tissues, particularly in their buccal
aspect, in fine biotypes (Kan et al. 2011b). In contrast to what is observed in the oral
mucosa, the study of the dynamic of the interproximal tissues in relation to the biotype
shows a weak correlation, without clinical significance (Kan et al. 2011b).
An often-understudied variable, of great relevance from an aesthetic perspective, is
the thickness of the peri-implant tissue in relation to its capacity to “hide” the underlying
restorative layer and the changes in gingival colouration that can be produced and lead
to an unsatisfactory result. In a spectrophotometric study carried out on porcine palates,
Jung et al. (2007) evaluated the importance of the gingival thickness in the mimicking of
different types of restorative materials (titanium, ceramicized titanium, zirconium, and
ceramicized zirconium). These authors observed that a tissue thickness of 1.5 mm always
induced a clinically perceptible discoloration, independently of the underlying restorative
material. It was also observed that only a gingival thickness close to 3 mm would allow
the hiding of any of the studied restorative materials, while a thickness close to 2 mm
only managed to mask the restorative layer if the material was of a favourable colour
(zirconium or ceramicized zirconium). Paniz et al. (2014), using a methodology of visual
analysis and a prior spectrophotometric (Bressan et al. 2011), reached a similar conclusion
in their clinical study regarding the influence of the material of the abutments on the
appearance of the peri-implant soft tissue.
Rungcharassaeng et al. (2012) – in a clinical analysis aimed at evaluating the change
of gingival thickness from extraction to the placement of an immediate implant with
immediate provisionalization and over the six months following the surgical intervention,
in the first disconnection of the temporary abutment and the taking of impressions for the
definitive restoration –concluded that the necessary thickness to mask the discoloration
produced by the prosthetic abutment could not be obtained without modifying the mucosal
compartment through a connective-tissue graft. The authors of this study observed
an average buccal peri-implant tissue thickness of 1.42 mm in the extraction sockets
treated only with a bone graft compared with a 2.61 mm in the test group (bone graft
plus tunnelled connective tissue graft). In other words, the average gingival thickness
is generally not enough to be able to hide most restorative materials (Jung et al. 2007;
Rungcharassaeng et al. 2012).
The technique of bilaminar connective-tissue graft, simultaneous with post-extraction
implant placement and immediate provisionalization, was described for the first time by
Kan et al. (2005). Since then, various studies have confirmed the effect of this technique
on the stabilization of the peri-implant tissue (Cornelini et al. 2008; Kan et al. 2009;
Tsuda et al. 2011; Chung et al. 2011; Noelken et al. 2018) and on the mimicking of the
restorative layer (Rungcharassaeng et al. 2012).
We illustrate the TABM therapy with the case of a 53-year-old patient with no medical
history of note and an invasive unrestorable cervical resorption of Heithersay class 4
(Heithersay 2004) without symptomology in the central right maxillary incisor (Figure
6). It is interesting to observe the proliferative character of the connective-tissue graft,
corresponding to the coronal growth observed both in the implant and in tooth 21, in the
follow-up to the case seven years after the cementing of the ceramic restoration.
48
Figure 6.1.
Illustration of the TA protocol with modification of the bone compartment (bone graft) and the mucosal
compartment (envelope connective-tissue graft) (TABM).
Figure 6.2.
Initial appearance in the zone of the incisors to treat.

Probing of the tooth affected by the root resorption Detail of the root remnant once dislocated and before Provisional crown, placed after rebasing and
process. its removal. polished.
49

Filling the bone gap with the xenograft. Preparation of the envelope bed in the area of both Appearance of the treated area before introducing
central incisors. the connective-tissue graft.

Connective-tissue graft before being placed into Detail of the provisional crown at 3 months. Taking the impression of the implant.
the envelope.
Figure 6.12.
Zirconium abutment screwed onto the implant
before the cementing of the definitive crown.

Definitive crown at the time of insertion. Appearance of the crown on the implant and of the tooth treated with the described mucogingival technique at
7 years of functioning.
50
THE PLAUSIBLE. TYPE II ALVEOLI

A HYPOTHESIS OR A CLINICAL CONCEPT can be considered “plausible” if it proposes
a convincing and admissible supposition this is a priori acceptable, even before carrying
out the necessary tests to confirm its exactitude or veracity. Our case will allude to a
clinical approach, still lacking in scientific backing but constructed under the hypothesis
of a clinical approach that respects and results from therapeutic bases that do enjoy such
backing.
We consider that TA is a plausible technique in type II alveoli because, if we have
an ideal level of soft tissue, the buccal defects of the bone crest can be handled through
guided bone regeneration (GBR) techniques in a tunnel approach, although of an
increased complexity when a flap is being raised. This approach, as well as being more
sensitive to the operator, lacks a scientific consistency, so it results in greater uncertainty
until there are sufficient studies to corroborate it.
One of the requirements established in the literature for the predictability of
immediate implants is the integrity of the alveolar socket, especially the buccal wall
which is the wall most susceptible to resorption. Its integrity allows a good condensation
of the bone graft and the placement of a connective-tissue graft (CTG) to avoid the loss of
horizontal volume. The total or partial absence of the buccal wall is relatively common.
Given that to maintain the aesthetics of the soft tissues it is recommended to perform
immediate implants without flap raising, it would be desirable to be able to place these
implants in type II alveoli. However, the lack of buccal bone wall considerably complicates
the bone regeneration of the socket, so as well as a bone graft a barrier membrane should
also be placed, following the principles of GBR but without raising a flap. The anatomy
of the ridge defect will be a determining factor and even narrow V-shaped defects can
have a potential for self-healing that does not require the use of barrier membranes.
Given that it is documented that even in cases of intact alveoli there tends to be a loss of
horizontal bone volume, this GBR procedure should be complemented with a CTG of the
palate to obtain an appropriate final emergence profile (Figure 7.1, graphic diagram of the
procedure). We describe the clinical approach below.
A 32-year-old woman, ex-smoker, who presents an apical fistula, mobility, and
progressive fanning of tooth 21. After the clinical and radiographic examination, it is
determined that the alveolar socket presents intact palatal, mesial, and distal walls and
that the buccal wall is completely resorbed. Five years after the treatment, the implant-
supported restoration presented a healthy and satisfactory clinical and radiographic state
(Figure 7).
The approach towards type II alveoli that we propose involves the placement of
implants in a way that is very similar to that carried out with the intact socket, except
that a collagen membrane is placed to compensate for the absence of the buccal wall.
In our opinion, another key factor is the overextension of the full-thickness recipient
bed that is prepared in the form of an envelope, which also allows the condensation of the
xenograft and the placement of the collagen membrane following the precepts of GBR.
Another factor to emphasize when adopting this approach is the use of a xenograft
made of hydroxyapatite and collagen, as it provides a more compact consistency that
prevents its spreading within the defect and is therefore easier to condense.
This clinical approach is more comfortable for the patient and provides better
aesthetics than the approach known as “early placement”, as from the very first day the
patient bears a fixed provisional restoration, and it better maintains the contour of the
soft tissues.
The treatment of type II alveoli with immediate implants does not have extensive
support in the scientific literature and should be performed by clinicians who are
experienced in type I immediate implants and in GBR procedures. Traditionally, in
cases where a bone defect is observed in the buccal aspect of the alveolar socket, deferred
implant placement associated with simultaneous procedures of bone and mucosa
regeneration has been proposed (Garber et al. 2001; Kan et al. 2007; Belser et al. 2009),
because the absence of the buccal bone wall and mucosal support that this provides could
lead to a buccal recession and the loss of interproximal tissue (Cosyn et al. 2012).
51
Nonetheless, recent publications have documented guided bone regeneration

simultaneously with immediate implant placement, with the aim of repairing the defect
described above. In these regenerations, the importance of the topography of the defect in
relation to the stability of the soft tissues is emphasized – particularly the impact of the
alveolar architecture of the adjacent teeth in the aspect immediately proximal to the bone
(Kan et al. 2007). Noelken et al. (2011) published a study which analysed the survival
and the pink aesthetic score (PES; Fürhauser et al. 2005) in a group of 16 patients with
non-restorable vertical fractures and complete loss of the buccal bone wall. Flapless
extractions were made, followed by immediate implants and guided bone regeneration
with autogenous bone (without using the barrier or membrane method) to fill the bone
compartment. The authors reported a survival rate of 100% and an average PES of 12.5
(range 10-14). In a study of type II alveoli using a similar therapeutic approach – the
authors deployed a cortical-trabecular block of the maxillary tuberosity together with a
connective-tissue graft of the same anatomical region – Martins da Rosa et al. (2014a)
observed stability in the peri-implant tissues 58 months after the placement of the post-
extraction implant, simultaneously with provisionalization and the regeneration described
above. Despite not using membrane in these two clinical experiments, the results were
satisfactory, from the point of view of the short- to medium-term stability of the buccal
peri-implant mucosa. However, the non-use of a barrier method to reduce bone modelling
and improve the bone incorporation is questionable: there is little quantitive evidence
in relation to how much the horizontal dimension of the buccal wall can be augmented,
specifically without following the classical principles of guided bone regeneration
(Gielkens et al. 2008). Although two publications have shown promising results in the
application of the GBR principles in post-extraction implants in a minimally invasive
(flapless) way, their sample sizes or follow-up appear limited and, at the time of writing
this article, it still seems premature to extrapolate clinical recommendations. Sarnachiaro
et al. (2016) analysed the effectiveness of this technique in a case series of 10 patients in
which immediate implants using the flapless protocol were implemented, with bone graft
and barrier membrane but without employing an immediate provisional. They ended with
clinical results which, maintaining an adequate gingival architecture, obtained buccal
Figure 7.1. bone widths, measured in CBCT, of between 2 and 3 mm. On the other hand, Gónzalez
Illustration of the TABM protocol implemented et al. (2018), in a case report, proposed a surgical technique for the treatment of type
using a collagen membrane for the treatment of II alveoli (which we also present in this article) in which, in addition to an immediate
type II alveoli.
implant in the flapless protocol with an immediate provisional, a bone graft (xenograft),
a barrier membrane, and an envelope connective-tissue graft was used (the “three-layer
technique” according to the name proposed by the authors).
It is necessary to carry out more controlled scientific studies on this approach, but in
our opinion electing the case in non-smoking patients and neatly applying the principles
of GBR, this technique – in the hands of experienced surgeons – can be deployed with a
high degree of predictability.

Peri-apical radiograph of the affected incisor. Detail of the affected incisor and the anterosuperior sextant.
52

Tooth extracted together with the apical granuloma Instrument used to shape the infra-periosteal Position of the membrane over the xenograft
that it presented. envelope before inserting the xenograft. before inserting the connective-tissue graft.

Detail of the connective-tissue graft before its Occlusal appearance of the three layers (xenograft, Frontal view of the provisional crown.
insertion into the bed. collagen membrane, and connective-tissue graft)
before the insertion of the provisional crown.

Clinical appearance of the restoration 5 years after its insertion. Radiological appearance of the implant-supported
crown at 5 years.
53
THE IMPONDERABLE. TYPE III ALVEOLI

WE CATALOGUE A CLINICAL APPROACH as “imponderable” when it takes place in
an unpredictable way or whose consequences cannot be estimated or specified. Thus, the
clinical result, although possible, is not based on plausible foundations and therefore its
predictability falls within the field of uncertainty.
We consider TA to be an imponderable technique in type III alveolar sockets, as the
defects that involve the loss of the buccal bone crest, when accompanied by soft-tissue
recessions, oblige using complex reconstruction techniques whose execution obliges certain
clinical virtuosities that sometimes conflict with the fundamentals of the techniques used
(Martins da Rosa et al. 2013, 2014b).
At the latest periodontology workshop (Tonetti et al. 2019), the little available evidence
about the treatment of this type of alveolus in an immediate way was highlighted. These
techniques are limited to a number of experienced clinicians and to carefully selected
patients (Gallucci et al. 2018). It is important to argue in this section that Elian type III
alveoli (Elian et al. 2007) have to be conceived under this focus in those situations where
the architecture of the soft tissues and the bone crest of the affected tooth differ from the
harmony of the dentition as a whole as, in those treated periodontal patients who suffer
from a reduced periodontium, an affected tooth with soft tissues and alveolar structure in
concordance with the adjacent teeth would be considered at the therapeutic level as if it
were a type I alveolus, although in a strict sense it can be defined as a type III (because
of the gingival retraction and the resorption of the bone crest). We describe the clinical
approach below.
We present the case of a 55-year-old female patient, with no medical history of
interest, who presented with inflammation, mobility, and pain in tooth 21. In the clinical
examination, a recession of 2.5 mm in the gingival margin was observed, resulting in
asymmetry with the contralateral tooth and which is evident because of the presence of
a high gingival smile (more than 3mm). In the periodontal examination, an abscess was
observed in buccal, with mobility of the clinical crown resulting from a horizontal crown
fracture. Probing depths of 8 mm in the mesiobuccal point, 20 mm in the centre-buccal,
and 7 mm in the distal-buccal, which defines a deep and wide bone defect compatible with
an inflammatory lesion caused by an external root resorption in the coronal third of the
root which extends to the middle third. A priori we catalogue the alveolar socket as a type
III of the classification cited above. A poor prognosis is thus assigned (Cabello et al. 2005,
2009) and it is decided (with the agreement of the patient) to proceed to extraction and
the immediate approach using the modified TABM approach, in having also to correct
the gingival recession at the same time (Figure 8). At the check-up of the implant after
six-and-a-half years we could observe the success of the treatment (absence of biological
and mechanical complications) over this medium term, as well as the patient’s great
satisfaction.
As with the treatment using TABM in type II alveoli extrapolates the experience and
the protocol of type I alveoli, the treatment of type III alveoli is justified in the same way
in which we act with type II alveoli, with the exception that the mucosal compartment
has to be displaced coronally because of the presence of a recession. The possibility of
performing the TABM clinical procedure with a bilaminar technique can be complex, as
it is necessary to remove the internal epithelium of the pocket in the surgical act, with
the aim of creating an adequate vascular bed to receive the soft-tissue graft and at the
same time achieve a coronal displacement of the margin. The gingival recession present in
type III alveoli is generally provoked by a previous bone dehiscence caused by an acute or
chronic inflammatory process maintained over time, which typically corresponds to a bone
defect of a greater size, and which tends also to affect the interproximal areas and even
the palatal region. As a result, the regenerative potential of the zone is lower, and the type
of defect is not self-contained.
54

Initial situation. Initial smile.

Extraction of the coronal fragment. Intrasulcular incision to make the envelope.
Figure 8.3.
Initial radiograph.

Coronal displacement of the flap. Detail of the connective-tissue graft.

Atraumatic extraction (Benex®). Placement of the implant in the post-extraction
alveolar socket.
55

Filling the gap with the xenograft. A provisional titanium abutment reline with the egg Insertion of the provisional.
shell technique.

Suture with vertical mattress stitches anchored to Image of the immediate post-operation. Cicatrization at 4 weeks.
the provisional restoration to obtain the coronal
repositioning.

X-ray at 6.5 years control. Appearance of the definitive crown at 6.5 years.
DISCUSSION
IN THE DEVELOPMENT OF THE TOPIC REVIEWED in this article, we have tried not
only to provide an update on TA but also to introduce new trends in this area. It is the
role of clinicians and researchers not only to review the clinical trials that evaluate the
effectiveness of the compared techniques but also open new hypotheses that allow the
generation of new research. This will allow a constant feedback into clinical science in
which we seek that the imponderable becomes plausible, the plausible predictable, and the
predictable is able to be simplified or modified under a new paradigm.
56
This article therefore provides an update on the clinical procedure of the immediate
implant with immediate provisional in the flapless protocol (trimodal approach), which
reviews the scientific evidence on its use on intact alveoli, paying attention to the
technique without modification of the bone or mucosal compartments (TA) as well as to
the procedures in which the gap is filled with a bone graft (TAB) or, in addition to acting
on this compartment, there is also an overcontouring of the buccal soft tissue with an
envelope connective-tissue graft (TABM). Clinical protocols have also been introduced in
which the technique could be useful both in the treatment of type II alveoli (in the section
on “the plausible”) and of type III alveoli (albeit with the handicap of forming part of “the
imponderable”).
CONCLUSIONS
IN ACCORDANCE WITH THE CONTENTS OF THIS ARTICLE, we can conclude the
following:
- The technique of immediate implant with an immediate provisional in the flapless
protocol (trimodal approach, TA) has been seen as a technique that can cut treatment
times, reduce morbidity, increase psychological acceptance by patients, and optimize
aesthetic and functional results. The presence of an intact alveolar socket (type II) can
be a determining factor for the predictability of the procedure.
- In the procedure without modifying the bone or mucosal compartments (TA), various
studies conclude that it tends to produce a recession of around 0.5-0.8 mm, and there
is a certain consensus (but not unanimity) in highlighting the importance of the
thickness of the biotype/phenotype on the result.
- In the approach mentioned, the use of an immediate provisional of anatomic profile
is one of the crucial factors for achieving the ideal aesthetic result, as this provisional
(according to the hypothesis of the authors themselves), through “inhibition by
contact”, excludes the proliferation of tissue with more rapid tissue kinetics (epithelial
and connective), promotes the positional stability of the peri-implant gingival margin
(restorative tissue inhibition), and can even minimize fascicular bone resorption
(although this lacks evidence at the experimental level).
- The TAB variant consists of the use of a bone graft to fill the gap between the bone
graft and the implant (documented particularly with xenografts), and it seems
that it compensates in part for the resorption of the coronal part of the fasciculated
crestal bone (bundle bone). It has not been possible to quantify precisely how this
phenomenon translates to the recession of the peri-implant gingival margin.
- The TABM variant consists of implementing the gap filling with a bone graft plus the
use of an envelope connective-tissue graft, a procedure that seems to be associated
with a gingival recession close to zero and in some cases a certain coronal growth of
the tissue. Furthermore, the use of the connective-tissue graft allows thickening the
buccal gum, which is advantageous for reducing aesthetic risks derived from a gingival
tissue that allows the presence of certain metallic restorative materials to show
through.
- The treatment of type II alveoli with this technique is an approach lacking in scientific
support, although the suggested clinical approach is based on plausible arguments
in which the TABM approach is combined with the use of a barrier membrane that
allows the bases of the traditional guided bone regeneration to be respected (three-
layer technique).
- The treatment of type III alveoli is beyond the framework of the plausible, which
means a degree of uncertainty in terms of the desired clinical result. In this case, the
case selection and the acceptance of the risks by the patient are mandatory, and the
TABM approach should be combined with the use of barrier membranes together
with techniques that allow a certain coronal repositioning of the tissue. The example
of the TABM technique in type III alveoli presents a series of limitations that restrict
its routine application, such as operator skill/experience or the presence of a serious
inflammatory situation of the tissues that has not been controlled previously.
- All these procedures demand a solid clinical experience, especially when applied to
type II or III alveoli.
57
CLINICAL RELEVANCE
THIS ARTICLE seeks to offer an update of a technique that is often indicated in
the clinic as is that of immediate implants with an immediate provisional in a
flapless protocol (trimodal approach), reviewing those procedures that have firm
scientific backing (type I alveoli), detailing its therapeutic variations (TA, TAB,
and TABM), and at the same time introducing new protocols for approaching
challenging clinical situations (type II and III alveoli).
Akimoto K, Becker W, Persson R, Baker DA, Rohrer MD, Botticelli D, Berglundh T, Buser D, Lindhe J. (2003a) Chen ST, Wilson TG Jr, Hämmerle CH. (2004)
O’Neal RB. (1999) Evaluation of titanium implants Appositional bone formation in marginal defects Immediate or early placement of implants following
placed into simulated extraction sockets: A study at implants. Clinical Oral Implants Research 14, 1-9. tooth extraction: review of biologic basis, clinical
in dogs. The International Journal of Oral and Botticelli D, Berglundh T, Lindhe J. (2003b) The jumping procedures, and outcomes. The International
Maxillofacial Implants 14, 351-360. distance revisited: An experimental study in the dog. Journal of Oral and Maxillofacial Implants 19 Suppl,
Araújo MG, Sukekava F, Wennström JL, Lindhe J. (2005) Clinical Oral Implants Research 14, 35-42. 12-25.
Ridge alterations following implant placement in Chen ST, Darby IB, Reynolds EC. (2007) A prospective
Bressan E, Paniz G, Lops D, Corazza B, Romeo E, Favero
fresh extraction sockets: an experimental study in clinical study of non-sumerged immediate implants:
G. (2011). Influence of abutment material on the
the dog. Journal of Clinical Periodontology 32, 645- clinical outcomes and esthetic results. Clinical Oral
gingival color of implant supported all-ceramic
652. Implants Research 18, 552-562.
restorations: a prospective multicenter study. Clinical
Araújo MG, Sukekava F, Wennström JL, Lindhe Oral Implants Research 22, 631-637. Chen ST, Buser D. (2009) Clinical and esthetic outcomes
J. (2006a) Tissue modelling following implant of implants placed in postextraction sites. The
placement in fresh extraction sockets. Clinical Oral Buser D, Martin W, Belser UC. (2004) Optimizing
International Journal of Oral and Maxillofacial
Implants Research 17, 615-624. esthetics for implant restorations in the anterior Implants 24 Suppl, 186-217.
maxilla: Anatomic and surgical considerations.
Araújo MG, Wennström JL, Lindhe J. (2006b) Modeling The International Journal of Oral and Maxillofacial Chen ST. (2009) Immediate implant placement
of the buccal and lingual bone walls of fresh Implants 19 Suppl, 43-61. postextraction without flap elevation. Journal of
extraction sites following implant installation. Periodontology 80, 163-172.
Clinical Oral Implants Research 17, 606-614. Cabello G, Aixelá ME, Casero AI, Calzavara D, González
D. (2005) Pronóstico en periodoncia. Análisis Chung S, Rungcharassaeng K, Kan JY, Roe P, Lozada
Araújo MG, Linder E, Lindhe J. (2009) Effect of a factores de riesgo y propuesta de clasificación. JL. (2011) Immediate single tooth replacement with
xenograft on early bone formation in extraction Periodoncia y Osteointegración 15, 93-110. subepithelial connective tissue graft using platform
sockets: an experimental study in dog. Clinical Oral switching implants: A case series. Journal of Oral
Implants Research 20, 1-6. Cabello G, Casero AI, Aixelá M, González D, Giménez Implantology 37, 559-569.
Fábrega J. (2009) Pronóstico en prótesis fija
Araújo MG, Linder E, Lindhe J. (2011) Bio-Oss Collagen implanto y dentosoportada. Recomendaciones para Cornelini R, Scarano A, Covani U, Petrone G, Piattelli A.
in the buccal gap at immediate implants: A 6-month un plan de tratamiento contemporáneo basado en (2000) Immediate one-stage postextraction implant:
study in the dog. Clinical Oral Implant Research 22, la evidencia. RCOE 14. a human clinical and histological case report. The
1-8. International Journal of Oral and Maxillofacial
Cabello G, Rioboo M, Giménez Fábrega J. (2013) Implants 15, 432-437.
Artzi Z, Tal H, Davan D. (2000) Porous bovine bone
Immediate placement and restoration of implants
mineral in healing of human extraction sockets. Cornelini R, Barone A, Covani U (2008). Connective
in the esthetic zone with a Trimodal Approach: soft
Part 1: histomorphometric evaluations at 9 months. tissue grafts in postextraction implants with
tissue alterations and its relation to gingival biotype.
Journal of Periodontology 21, 1015-1023. immediate restoration: A prospective controlled
Clinical Oral Implants Research 24, 1094-1100.
Atieh MA, Payne AGT, Duncan WJ, Cullinan MP. (2009) clinical study. Practical Procedures & Aesthetic
Immediate restoration/loading of immediate placed Cabello G, Fernández DA, Calzavara D, Fábrega JG. Dentistry 20, 337.
single implants: is it an effective bimodal approach? (2015) Inmediate placement and restoration of Cosyn J, Sabzevar MM, De Bruyn H. (2012) Predictors
Clinical Oral Implants Research 20, 645-659. implants in the esthetic zone: Trimodal Approach of inter-proximal and midfacial recession following
therapeutic options. The International Journal of single implant treatment in the anterior maxilla:
Belser UC, Schmid B, Higginbottom F, Buser D. (2004) Esthetic Dentistry 10, 100-121.
Outcomes analysis of implant restorations located in A multivariate analysis. Journal of Clinical
the anterior maxilla: A review of the recent literature. Cardaropoli D, Debernardi C, Cardaropoli G. (2007) Periodontology 39, 895-903.
The International Journal of Oral and Maxillofacial Immediate placement of implant into impacted De Rouck T, Collys K, Cosyn J. (2008) Immediate single-
Implants 10 Suppl, 30-42. maxillary canine extraction socked. The International tooth implants in the anterior maxilla: A 1-year
Journal of Periodontics & Restorative Dentistry 27, case cohort study on hard and soft tissue response.
Belser UC, Grütter L, Vailati F, Bornstein MM, Weber 71-77.
HP, Buser D. (2009) Outcome evaluation of early Journal of Clinical Periodontology 35, 649-657.
placed maxillary anterior single-tooth implants Carlsson L, Rostlund T, Albrektsson B, Albrektsson Elian N, Cho SC, Froum S, Smith RB, Tarnow DP.
using objective esthetic criteria: A cross-sectional, T. (1988) Implant fixation improved by close fit. (2007) A simplified socket classification and repair
retrospective study in 45 patients with a 2 to 4 year Cylindrical implant-bone interface studied in rabbits. technique. Practical Procedures and Aesthetic
follow-up using Pink and White Esthetic Scores. Acta Orthopaedica Scandinavica 59, 272-275. Dentistry 19, 99-104.
Journal of Periodontology 80, 140-151. Carmagnola D, Adriaensens P, Berglundh T. (2003) Evans CD, Chen ST. (2008) Aesthetic outcomes of
Berglundh T, Lindhe J. (1997) Healing around implants Healing of human extraction sockets filled with Bio- immediate implant placements. Clinical Oral
placed in bone defects treated with Bio-Oss. An Oss. Clinical Oral Implants Research 20, 137-143. Implants Research 19, 73-80.
experimental study in the dog. Clinical Oral Implants Chang M, Odman PA, Wennström JL, Andersson B. Fickl S, Zuhr O, Wachtel H, Boltz W, Hurzeler M. (2008a)
Research 8, 117-124. (1999) Esthetic outcome of implant-supported Tissue alterations after tooth extraction with and
Bianchi AE, Sanfilippo F. (2004) Single-tooth single-tooth replacements assessed by the patient without surgical trauma: A volumetric study in the
replacement by immediate implant and connective and by prosthodontists. The International Journal of beagle dog. Journal of Clinical Periodontology 35,
tissue graft: a 1-9 year clinical evaluation. Clinical Prosthodontics 12, 335-341. 356-363.
Oral Implant Research 15, 269-277. Chaushu G, Chaushu S, Tzohar A, Dayan D. (2001) Froum S, Cho SC, Rosemberg F, Rohrer M, Tarnow
Blanco J, Nuñez V, Aracil L, Muñoz F, Ramos I. (2008) Immediate loading of single tooth implants: D. (2002) Histological comparison of healing
Ridge alterations following inmediate implant Immediate versus non-immediate implantation. A extraction sockets implanted with bioactive glass or
placement in the dog: Flap versus flapless surgery. clinical report. The International Journal of Oral and demineralized freeze dried bone allograft. Journal of
Journal of Clinical Periodontology 35, 640-648. Maxillofacial Implants 16, 267-272. Periodontology 73, 94-102.
58
Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, Lang NP, Tonetti MS, Suvan JE, Pierre Bernard J, Botticelli Quirynen M, Van Assche N, Botticelli D, Berglundh T.
Watzek G. (2005) Evaluation of soft tissue around D, Fourmousis I, Hallund M, Jung R, Laurell L, Salvi (2007) How does the timing of implant placement
single-tooth implant crowns: The pink esthetic GE, Shafer D, Weber HP. (2007) Immediate implant to extraction affect outcome? The International
score. Clinical Oral Implants Research 16, 639-644. placement with transmucosal healing in areas Journal of Oral and Maxillofacial Implants 22 Suppl,
of aesthetic priority. A multicentre randomized- 203-223.
Gallucci GO, Hamilton A, Zhou W, Buser D, Chen S.
controlled clinical trial. I. Surgical outcomes. Clinical Roe P, Kan JY, Runcharassaeng K, Caruso JM,
(2018) Implant placement and loading protocols in
Oral Implant Research 19, 188-196. Zimmerman G, Mesquida J. (2012) Horizontal
partially edentulous patients: A systematic review.
Clinical Oral Implants Research 29 Suppl 16, 106- Lee CT, Tao CY, Stoupel J. (2016) The effect of and vertical dimensional changes of peri-implant
134. subepithelial connective tissue graft placement facial bone following immediate placement
on esthetic outcomes after immediate implant and provisionalization of maxillary anterior
Garber DA, Salama MA, Salama H. (2001) Immediate single implants: A 1-year cone beam computed
placement: Systematic review. Journal of
total tooth replacement. Compendium of tomography study. The International Journal of Oral
Periodontology 87, 156-167.
continuing education in dentistry (Jamesburg, N.J.: & Maxillofac Implants 27, 393-400.
1995) 22, 210-218. Libman WJ, Nicholls JI. (1995) Load fatigue of teeth
restored with cast posts and cores and complete Rungcharassaeng K, Kan JY, Yoshino S, Morimoto
Gielkens PF, Schortinghuis J, de Jong JR, Paans AM, crowns. The International Journal of Prosthodontics T, Zimmerman G. (2012) Immediate implant
Ruben JL, Raghoebar GM, Stegenga B, Bos RR. 8, 155-161. placement and provisionalization with and without
(2008) The influence of barrier membranes on a connective tissue graft: An analysis of facial
autologous bone grafts. Journal of Dental Research Martins da Rosa JC, Pértile de Oliveira AC, Martins
gingival tissue thickness. The International Journal
87, 1048-1052. Da Rosa D, Zardo CM. (2013) Immediate
of Periodontics & Restorative Dentistry 32, 657-663.
dentoalveolar restoration of compromised sockets:
González D, Cabello G, Olmos G, López Hernández A novel technique. The European Journal of Esthetic Sarnachiaro GO, Chu SJ, Sarnachiaro E, Gotta SL,
E, Niñoles CL. (2018) The three-layer technique Dentistry 8, 432-443. Tarnow DP. (2016) Immediate implant placement
for immediate implants on teeth without a buccal into extraction sockets with labial plate dehiscence
bone wall: a case report. The International Journal Martins da Rosa JC, Martins da Rosa D, Fadanelli defects: A clinical case series. Clinical Implant
MA, Sotto-Maior BS. (2014) Immediate implant Dentistry and Related Research 18, 821-829.
of Esthetic Dentistry 13, 2-20.
placement, reconstruction of compromised sockets,
Groisman M, Frossard WM, Ferreira HM, De Menezes and repair of gingival recession with a triple graft Schropp L, Kostopoulos L, Wenzel A. (2003a) Bone healing
Filho LM, Touati B. (2003) Single tooth implants from the maxillary tuberosity: A variation of the following immediate versus delayed placement
in the maxillary incisor region with immediate immediate dentoalveolar restoration technique. The of titanium implants into extraction sockets: a
provisionalization: 2 year prospective study. Practical Journal of Prosthetic Dentistry 112, 717-722. prospective clinical study. The International Journal of
Procedures and Aesthetic Dentistry 15, 115-122. Oral and Maxillofacial Implants 18, 189-199.
Martins da Rosa JC, de Oliveira Rosa ACP, Francischone
Heithersay GS. (2004) Invasive cervical resorption. CE, Sotto-Maior BS. (2014) Esthetic outcomes Sorensen JA, Engelman MJ. (1990) Ferrule design and
Endodontic Topics 7, 73-92. and tissue stability of implant placement into fracture resistance of endodontically treated teeth.
compromised sockets following immediate The Journal of Prosthetic Dentistry 63, 529-536.
Jung RE, Sailer I, Hämmerle CH, Attin T, Schmidlin P.
(2007) In vitro color changes of soft tissues caused dentoalveolar restoration: Results of a prospective Tonetti MS, Jung RE, Ávila-Ortiz G, Blanco J, Cosyn
by restorative materials. The International Journal of case series at 58 months follow-up. The International J, Fickl S, Figuero E, Goldstein M, Graziani F,
Periodontics Restorative Dentistry 27, 251-257. Journal of Periodontics & Restorative Dentistry 34, Madianos P, Molina A, Nart J, Salvi GE, Sanz-Martín
199-208. I, Thoma D, Van Assche N, Vignoletti F. (2019)
Juodzbalys G, Wang HL. (2007) Soft and hard tissue Management of the extraction socket and timing
assessment of immediate implant placement: A case Nevins M, Camelo M, De Paoli S, Friedland B, Schenk R,
of implant placement: Consensus report and clinical
series. Clinical Oral Implants Research 18, 237-243. Parma Benfenati S, Simion M, Tinti C, Wagenberg
recommendations of group 3 of the XV European
B. (2006) A study of the fate of the buccal wall
Kan JY, Rungcharassaeng K, Lozada J. (2003) Immediate Workshop in Periodontology. Journal of Clinical
of extraction sockets of teeth with prominent
placement and provisionalization of maxillary Periodontology 46 Suppl 21, 183-194.
roots. The International Journal of Periodontics &
anterior single implants: 1-year prospective study. Restorative Dentistry 26, 19-29. Tsuda H, Rungcharassaeng K, Kan JY, Roe P, Lozada
The International Journal of Oral and Maxillofacial JL, Zimmerman G. (2011) Peri-implant tissue
Noelken R, Kunkel M, Wagner W. (2011) Immediate
Implants 18, 31-39. response following connective tissue and bone
implant placement and provisionalization after
Kan JY, Rungcharassaeng K, Lozada JL. (2005) Bilaminar grafting in conjunction with immediate single-tooth
long-axis root fracture and complete loss of the replacement in the esthetic zone: A case series.
subepithelial connective tissue grafts for immediate facial bony lamella. The International Journal of
implant placement and provisionalization in the The International Journal of Oral and Maxillofacial
Periodontics & Restorative Dentistry 31, 175-183. Implants 26, 427-436.
esthetic zone. Journal of the California Dental
Noelken R, Moergel M, Pausch T, Kunkel M, Wagner Vacek JS, Gher ME, Assad DA, Richardson AC,
Association 33, 865-971.
W. (2018) Clinical and esthetic outcome with Giambarresi LI. (1994) The dimensions of the human
Kan JY, Rungcharassaeng K, Sclar A, Lozada JL. (2007) immediate insertion and provisionalization with or dentogingival junction. The International Journal of
Effects of the facial osseous defect morphology without connective tissue grafting in presence of Periodontics & Restorative Dentistry 14, 154-165.
on gingival dynamics after immediate tooth mucogingival recessions: A retrospective analysis
replacement and guided bone regeneration: 1-year with follow-up between 1 and 8 years. Clinical Vignoletti F, de Santis M, Berglundh T, Abrahamsson
results. Journal of Oral & Maxillofacial Surgery 65 Implant Dentistry and Related Research 20, 285- I, Sanz M. (2009) Early healing of implants placed
Suppl 1, 13-19. 293. into fresh extraction sockets: An experimental study
in the beagle dog. III Soft tissue findings. Journal of
Kan JY, Rungcharassaeng K, Morimoto T, Lozada Norton MR. (2004) A short-term clinical evaluation of Clinical Periodontology 36, 1059-1066.
J. (2009) Facial gingival tissue stability after immediately restored maxillary TiOblast single-tooth
implants. The International Journal of Oral and Wilson TG, Schenk R, Buser D, Cochran D. (1998)
connective tissue graft with single immediate tooth
Maxillofacial Implants 19, 274-281. Implants placed in immediate extraction sites: A
replacement in the esthetic zone: Consecutive case
report of histological and histometricanalysis of
report. Journal of Oral and Maxillofacial Surgery 67 Nowzari H, Molayem S, Ching HKC, Rich SK. (2012) human biopsies. The International Journal of Oral
Suppl 3, 40-48. Cone beam computed tomographic measurement and Maxillofacial Implants 13, 333-341.
Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman of maxillary central incisors to determine prevalence
Wöhrle P. (1998) Single-tooth replacement in the
G. (2011) Facial gingival tissue stability following of facial alveolar bone width ≥2mm. Clinical Implant
esthetic zone with immediate provisionalization:
immediate placement and provisionalization of Dentistry and Related Research 14, 595-602.
Fourteen consecutive case reports. Practical
maxillary anterior single implants: A 2- to 8-year Palattella P, Torsello F, Cordaro L. (2008) Two-year Periodontics and Aesthetic Dentistry 10, 1107-1114.
follow-up. The International Journal of Oral and prospective clinical comparison of immediate
Maxillofacial Implants 26, 179-187. Yoshino S, Kan JY, Runcharassaeng K, Roe P. (2014)
replacement vs. immediate restoration of single
Effects of connective tissue grafting on the facial
Kan JYK, Roe P, Rungcharassaeng K, Patel R, Waki T, tooth in the esthetic zone. Clinical Oral Implants
gingival level following single immediate implant
Lozada JL, Zimmerman G. (2011) Classification Research 19, 1148-1153.
placement and provisionalization in the esthetic
of sagittal root position in relation to the anterior Paniz G, Bressan E, Stellini E, Romeo E, Lops D. (2014) zone: A 1-year randomized controlled prospective
maxillary osseous housing for immediate implant Correlation between subjective and objective study. The International Journal of Oral and
placement: A cone beam computed tomography evaluation of peri-implant soft tissue color. Clinical Maxillofacial Implants 29, 432-440.
study. The International Journal of Oral and Oral Implants Research 25, 992-996. Yuenyongorarn P, Kan JYK, Rungcharassaeng K,
Maxillofacial Implants 26, 873-876. Paolantonio M, Dolci M, Scaranao A, d’Archivio D, di Matsuda H, Roe P, Lozada JL, Caruso J. (2020)
Knox R, Caudill R, Meffert R. (1991) Histologic evaluation Placido G, Tumni V, Piatelli A. (2001) Immediate Facial gingival changes with and without socket
of dental endosseous implants placed into surgically implantation in fresh extraction sockets. A controlled gap grafting following single maxillary anterior
created extraction defects. The International Journal clinical and histological study in man. Journal of immediate tooth replacement: One-year results. The
of Periodontics & Restorative Dentistry 11, 365-375. Periodontology 72, 1560-1571. Journal of Oral Implantology 46, 496-505.
59
60
Clinical case
CRITICAL STEPS IN THE

IMPLEMENTATION OF THE
SOCKET SHIELD TECHNIQUE.
PHILIP STAEHLER, SOPHIA M. ABRAHA, ERDEM GUELNERGIZ, JOEL BASTOS SOUSA, OTTO ZUHR,
MARKUS HUERZELER.
Philip Staehler*. DMD, Private Practice, Munich,

Germany. INTRODUCTION
Sophia M. Abraha*. DMD, Private Practice,
Munich, Germany. PREDICTABLY PRESERVING the soft and hard tissue contour after tooth extraction
and immediate implant placement has been proven to be complicated. The reason for
Erdem Guelnergiz. DMD, Private Practice,
Munich, Germany.
this is because, after tooth extraction, an inevitable loss of periodontal ligament and
accompanying bundle bone occurs (Araujo et al. 2005). If the facial bone wall is thin
Joel Bastos Sousa. DMD, Private Practice,
and therefore mostly comprised of bundle bone, significant resorption in vertical and
Munich, Germany.
horizontal bone height can follow (Lee et al. 2014; Baeumer et al. 2017).
Otto Zuhr. DMD, Private Practice, Munich,
Germany and Department of Periodontology,
Johann-Wolfgang-Goethe University Frankfurt,
Frankfurt, Germany.
Markus Huerzeler. DMD, PhD, Private

Practice, Munich, Germany and Department
of Operative Dentistry and Periodontology,
Albert-Ludwigs-University Freiburg, Freiburg,
Germany.
Correspondence to:
Philip Staehler*
p.staehler@huerzelerzuhr.com
Sophia M. Abraha*
s.abraha@huerzelerzuhr.com
* Shared first authorship, both authors

contributed equally to the publication.
Philip Staehler Sophia M. Abraha Erdem Guelnergiz Joel Bastos Sousa
61 Otto Zuhr Markus Huerzeler

Different treatment modalities have been proposed to reduce compromising defect

formation in the esthetic zone (Esposito et al. 2012; Lin et al. 2014; Kan et al. 2018).
These techniques range from palatally oriented implant position with a navigated surgical
guide to platform switching, soft and hard tissue grafts and immediate provisionalisation.
Though the efficacy of these procedures has been clearly demonstrated, complete and
reliable preservation of the original soft and hard tissue contour is unlikely (Lee et al.
2014; Khzam et al. 2015). The socket shield technique was developed more than a decade
ago by this working group to achieve an uncompromised esthetic result (Huerzeler et al.
2010). Based on research about successful root retention techniques for alveolar ridge
preservation (Guyer 1975; Welker et al. 1978; Salama et al. 2007), the concept to partially
extract the root and leaving the intact buccal part of the root in place was shown to be
successful in ultimately preserving the buccal soft and hard tissues (Huerzeler et al. 2010;
Baeumer et al. 2017). Since the buccal part of the tooth stays in place, the resorption of
buccal bone and soft tissue is not initiated, therefore leaving the esthetically relevant
areas around the implant unchanged.
The socket shield technique is nowadays established in implant placement in the
esthetic zone. Since the first proof of principle report (Huerzeler et al. 2010), numerous
case reports (Caiazzo et al. 2013; Kan et al. 2013; Abadzhiev et al. 2014; Cherel et al.
2014; Glocker et al. 2014; Troiano et al. 2014; Gluckman 2015; Mahajan et al. 2015;
Mitsias et al. 2015; Gluckman et al. 2016; Mitsias et al. 2017; Petsch et al. 2017; Roe et al.
2017; Aslan 2018; Bramanti et al. 2018; Hinze et al. 2018; Kumar et al. 2018) and several
studies, including hundreds of patients, have shown favorable esthetic outcomes and long-
term results (Siormpas et al. 2014; Baeumer et al. 2017; Bramanti et al. 2018; Gluckman
et al. 2018, Han et al. 2018; Siormpas et al. 2018; Sun et al. 2020). The 5-year data
published by this working group demonstrated minor volumetric tissue changes following
implant placement (Baeumer et al. 2017). The latest systematic literature review by
Mourya et al. pointed in the same direction (Mourya et al. 2019) . Although the technique
allows for almost unchanged soft and hard tissue morphology around implants, socket
shield implant placement is technic-sensitive. Major possible complications like shield
exposure (Zuhr et al. 2020) can be avoided if specific guidelines are respected. With the
publication of a standardized treatment protocol (Staehler et al. 2020), the socket shield
treatment's predictability is expected to further increase in the literature.
Traditional implant placement protocols rely heavily on the preoperative evaluation
of the buccal bone thickness and soft tissue type. According to Buser et al. (Buser et al.
2017), immediate implant placement is only feasible in the esthetic zone when a thick
buccal bone wall and a thick gingival phenotype are present. Since this situation is
rarely found (Braut et al. 2011), most cases are treated with the early implant placement
protocol, dating back over 20 years. This delayed approach comprises tooth extraction and
a subsequent 4-8 week healing period. During this time, the typically thin buccal bone
will resorb. In order to nonetheless achieve satisfying esthetic results, bone augmentation
is necessary for the second step procedure. A mucoperiosteal flap is elevated, the implant
placed, the buccal bone dehiscence covered with autogenous bone chips and bovine bone
replacement material and the surgical site is closed primarily. After another waiting
period of 16 weeks, the implant is uncovered in a third surgical step (Buser et al. 2017).
Recent immediate implant placement concepts allow for immediate implantation
even in cases with a missing buccal bone wall or a thin gingival phenotype, that would
traditionally constitute a contraindication for immediate implantation. In cases of missing
buccal bone, the immediate dentoalveolar restoration concept by da Rosa (da Rosa et al.
2013) with bone grafting from the tuberosity or the concept by Noelken et. al. (Noelken et
al. 2018) with grafted bone chips from the mandibular ramus area can be applied. When
the gingival phenotype is thin, simultaneous connective tissue grafting can be an option to
overcome especially vertical defect formation (Seyssens et al. 2021).
62
Philip Staehler, Critical steps in the implementation of the socket shield technique Clinical case
Sophia M. Abraha et al.
Either of the aforementioned protocols rely on harvesting soft or hard tissues from an
additional donor site, thus creating additional morbidity for the patient. Whilst implant
dentistry in the past was able to meet patients' functional and later increasingly also
esthetic expectations, morbidity and concomitant patient-related factors have come into
focus. To address these issues, patient-reported outcome measures (PROMs) have become
essential treatment objectives in dentistry (John 2018). These PROMs typically include
questions regarding oral function, orofacial pain, orofacial appearance and psychosocial
impact (Mittal et al. 2019).
Implementing the socket shield technique as an immediate implant placement
technique with an open healing approach and direct integration of the emergence profile
can be an option to positively influence the PROMS by decreasing patient morbidity
without compromising the esthetic result. The need for additional soft or hard tissue
grafting is avoided, and immediate implantation with open healing can be performed,
regardless of the dimensions of the buccal bone wall or the gingival phenotype.
Therefore, the objective of the present narrative review is to assist dental practitioners
in safely implementing this technique by emphasizing the critical technical steps in the
execution.
METHOD
INITIALLY DEVELOPED OVER 10 YEARS AGO by this working group (Hurzeler
et al. 2010), the technique has been systematically applied and investigated in our
office over the last years. The complete preservation of the facial tissues was confirmed
volumetrically in a pilot study (Baeumer et al. 2013) and over 5 years (Baeumer et al.
2017). The preliminary data in preparation of publication for the 10-year results have
shown the same unchanged results in preserving the soft and hard tissues. Through
complications (Zuhr et al. 2020) and growing experience with this technique, we learnt
over the years to identify the critical surgical steps in this technique sensitive approach.
The first step is to design a three-dimensionally created surgical guide using a CBCT
and a digital intraoral model. By superpositioning the CBCT and the model, the palatally
oriented position of the implant can be precisely defined. The position of the implant
itself is not affected by the application of the socket shield technique, meaning the
palatal implant position and a screw-hole access from palatally is chosen as in any other
immediate or delayed implant placement protocol (Figure 1).
Figure 1.
CBCT planning showing the shield position in relation to the implant body. A mechanical locking approach is
possible, note the direct contact between shield and implant body in the apical part. The palatal position and the
angulation allow for bony ingrowth between implant body and shield in the coronal part.
63
Figure 2. Figure 3.
Showing a broken lateral incisor. Occlusal view of the gingival contour of the broken incisor.
The most significant experience over the last decade was that direct contact between
the socket shield, respectively the buccal dentine part of the partially extracted root,
and the implant suprastructure could cause infection and the shield's failure (Zuhr et al.
2020). Even if no initial contact between shield and implant suprastructure exists, the
lifelong skeletal maxillary growth in an antero-caudal direction (Bjork 1968; Bjork et al.
1977; Iseri et al. 1995) can possibly lead to a gradual displacement of the leftover root
fragment alongside the growth of the bone against the ankylosed implant suprastructure.
Once direct contact between the socket shield and the implant suprastructure is
established, the absent soft tissue barrier over the shield can facilitate infection through
the oral cavity bacteria (Zuhr et al. 2020). To avoid this kind of complication the antero-
Figure 4.
caudal displacement of the shield relative to the ankylosed implant needs to be prevented.
Preparation of the implant bed through the root
with a palatally shifted axis. This is preferably done mechanically by creating a direct contact between the implant
body and the dentine shield, thereby “locking” the shield to the implant body. In the
mandatory presurgical three-dimensional implant planning, the possible locking area can
be defined. The direct contact should be placed buccally to the implant in the apical part of
the shield. A direct contact between the shield and the implant in the coronal part has to
be avoided to allow ingrowth of bone between shield and implant in the coronal part. If the
implant and tooth axis differ so much, that a direct buccal contact between implant body
and shield cannot be realized, the contact between implant body and shield can instead
be located at the approximal side of the shield (Kan et al. 2013). In the rare case, where a
direct contact between implant body and shield cannot be accomplished, the shield is left
as long as possible, from 0.5mm above the buccal bone level to a point 3-4mm coronal to
the removed apex. This is termed a biological locking approach, because alongside the gap
between implant body and shield, an ingrowth of bone was shown (Huerzeler et al. 2010;
Schwimer et al. 2018), that leads to functional ankylosis of the shield.
Another meaningful experience was to cut off the crown and leave the complete root
in place during the implant bed preparation (Figure 2 and Figure 3). By drilling through
the root, the bur is guided partially by the dentine and partially by the palatal bone wall
(Figure 4). When using the different burs after the guided pilot bur, care must be taken to
push the bur against the dentine rather than the palatal bone wall. Since the dentine is
harder than the palatal bone, accidental "slipping" of the bur through the palatal bone can
be avoided.
64
Figure 5. Figure 6.
After preparation of the implant bed and extraction of the lateral and palatal root Concave preparation of the dentine shield with a carbide bur.
remnants as well as the apex. Notice the palatally oriented implant position.
Figure 7. Figure 8.
Occlusal view after final concave preparation of the dentine shield to 0.5mm above the bone crest. Checking for root fractures with methylene blue
staining solution.
After taking out the root's palatal segment, removing the leftover root canal filling
material and the apex under visual magnification is mandatory (Figure 5). The early
experiences in this working group showed, that leftover root canal filling or a leftover apex
can cause secondary inflammation to the implant and the apical bone. When removing the
apex with the small Lindemann bur, the non-dominant hand's fingertip should be pressed
against the corresponding apical part of the vestibule. This way, possible perforations to
the vestibule can be felt in advance.
Once the possibly infectious remnants of the root canal and root canal filling
materials have been removed, the shield's coronal part needs to be hollowed out in a
concave shape (Figure 6 and Figure 7). This will allow for a greater distance between
the later suprastructure and the shield, thus further reducing the direct shield's risk to
suprastructure contact. A minimum thickness of 1mm of the shield in an oro-vestibular
direction should not be undercut for sufficient shield stability. The coronal part of the
shield should be shortened to 0.5mm above the buccal bone crest. Before inserting the
implant, it is indispensable to check the shield for cracks (Figure 8). Endodontically
pretreated teeth have a higher chance of microfractures, which could cause problems in the
long term when used as a shield. This is performed with methylene blue staining solution.
65
Figure 9.
After insertion of a 3.5mm Thommen SPI Element RC implant on the level of the facial bone crest, 0.5mm below
the dentine shield. Note the missing direct contact coronally. Mechanical locking is solely realized further apically.
Figure 10.
Completed individual healing cap made from
flowable deep curing bulk fill composite.

Showing the final crown after two years of Occlusal view of the final crown after 2 years of function.
function.
Possible cracks are opened with the small Lindemann bur, separating the shield
into two parts. Importantly straight implants have an advantage compared to tapered
implants with the socket-shield techniques, if the surgeons are looking for a mechanical
locking on the buccal side (Figure 9). There is a high chance of cracking the buccal bone
with the shield towards the buccal side when a tapered implant is used to lock the shield
mechanically. After insertion of the implant on the level of the buccal bone, a provisional
abutment with an individualized emergence profile is intraoperatively created for an open
healing (Figure 10).
The buccal and occlusal pictures show the situation after 2 years. A stable gingival
contour and a volumetrically unchanged horizontal volume can be observed (Figure 11
and Figure 12).
66
DISCUSSION
AS A SPECIFIC FORM of immediate implant placement technique, the socket shield
technique has ultimately preserved the buccal implant surrounding tissues over five years
(Baeumer et al. 2017). The preliminary results of the same patient cohort's ten years data
in preparation for publication yielded the same unchanged tissue situation. The favorable
short- and long-term outcomes of the socket shield approach have also been documented
in various retrospective studies, including several hundred patients (Siormpas et al. 2014;
Gluckman et al. 2018; Han et al. 2018; Siormpas et al. 2018), randomized controlled clinical
trials (Bramanti et al. 2018; Abd-Elrahman et al. 2020; Sun et al. 2020), as well as one
recent systematic literature review (Mourya et al. 2019). For these reasons, the socket shield
technique is considered an established immediate implant placement technique.
Besides the objectively measurable outstanding esthetic results of the socket shield
technique, the technique can dramatically reduce patients' morbidity and improve PROMs
compared to traditional early implant placement protocols. As described above by Buser
et. al. (Buser et al. 2017), after evaluation of the buccal bone thickness, only a minority of
cases [around 5% (Braut et al. 2011)] can be treated using immediate implantation in their
opinion. According to their approach, when a minor or dehiscent buccal bone wall is present,
a delayed implantation is necessary. It requires three separate surgical procedures though,
including extraction, early open flap implant placement with simultaneous augmentation,
and the final implant's uncovering. The treatment takes at least 24 weeks of healing and
another couple of weeks until the uncovered implant soft tissue has settled (Buser et al.
2017).
Modern immediate implantation techniques with immediate bone or soft tissue
augmentation can mitigate patients' morbidity and reduce the number of separate surgical
procedures (Raghoebar et al. 2009; Noelken et al. 2018; Zufia et al. 2019; Seyssens et al.
2021; Slagter et al. 2021).
In all cases, where the buccal bone lamella is still present after extraction, the
application of a connective tissue graft concomitant to the immediate implantation has
shown to increase midfacial soft tissue stability (Seyssens et al. 2021). Even in lower risk
cases, where a thick buccal bone wall and a thick tissue phenotype is present, gingival
defect formation and midfacial recession can occur, creating the need for a reconstructive
soft tissue graft (Seyssens et al. 2020). Although the use of a connective tissue graft does
not seem to completely compensate for post-extractional soft and hard tissue changes, it
was shown, that a significantly more coronal position of the gingival margin around the
immediate implant can be expected after 12 months (van Nimwegen et al. 2018).
In complicated cases with missing buccal bone, modern immediate implantation
concepts still allow for immediate implantation and dentoalveolar reconstruction. Several
successful immediate implantation studies with simultaneous bone augmentation are
available in the literature (Raghoebar et al. 2009; Zufia et al. 2019). Slagter et al. (Slagter
et al. 2021) published the results of a five-year randomized controlled trial of an immediate
closed healing approach versus an delayed approach using tuberosity bone. All implants
from both groups constituted a treatment success without significant inter-group differences
regarding the pink esthetic score, peri-implant soft tissue changes or CBCT-analyzed bone
dimensions. Noelken et al. (Noelken et al. 2018) presented a case series where immediate
implantation, simultaneous augmentation with bone chips from the mandibular ramus and
immediate provisionalization was performed. The pink esthetic score (Furhauser et al. 2005)
improved throughout the treatment, and the implants performed well clinically with success
rates, according to Buser et al. (Buser et al. 1990) around 97%. After CBCT analysis of the
buccal bone wall though, the combined success rate dropped to 70% after five years, because
of partly non-detectable, clinically irrelevant buccal bone loss. A combined approach using
bone restauration with tuberosity grafts and simultaneous immediate provisionalization
was introduced by da Rosa et al. (da Rosa et al. 2013). In a case series with 20 patients,
successful integration and stability of the augmented buccal tuberosity bone was observed
over a mean period of 35 months (de Oliveira Rosa et al. 2016).
67
For harvesting the preventive connective tissue grafts or for bone defect augmentation
in immediate implantation cases, all of these innovative techniques rely on an autogenous
soft tissue or bone grafts, creating a second surgical donor site.
As an immediate implant placement technique, the socket shield technique not only
offers the advantages of an immediate implant placement approach. Together with the
open healing of the implant and the complete preservation of implant surrounding tissues
on the buccal side, this surgical technique omits the need for further soft and hard tissue
augmentation as well as implant uncovering procedures. Also, the thickness of the buccal
bone or the gingiva's phenotype are irrelevant since the preservation of the buccal root
shield does not evoke remodeling processes on the buccal side. The treatment time is
reduced to around ten weeks, the patient only has to undergo surgery and anesthesia once,
and the patients' overall in-office time is cut to fractions of comparable immediate or delayed
implant placement approaches. In 2004 it was shown that the patients' overall implant
treatment satisfaction was significantly higher when a minimized treatment duration
was achieved (Schropp et al. 2004). Patients who underwent the socket-shield technique
reported a very low postoperative morbidity (Baeumer et al. 2017).
Disadvantages socket shield

Although the socket shield technique offers unique advantages in esthetics and patient
morbidity, it is also a very technique sensitive procedure. The need for more than four
times visual magnification with direct illumination arises from the fact that the careful
preparation and partial extraction of the tooth require direct vision. Also, the implant
shoulder placement at the level of the bone, only 0.5mm below the shield, requires
a microsurgically trained professional. The socket shield surgery therefore takes
considerably longer than simple tooth extraction in delayed implant placement because of
its complexity. It is also important to respect the above mentioned critical surgical steps.
As published by our working group (Zuhr et al. 2020), the buccal dentine shield should be
mechanically anchored to the implant body to prevent further antero-caudal displacement
of the dentine shield. This possible displacement of the shield against the ankylosed
implant suprastructure can cause direct contact between the shield and the implant
suprastructure, which was shown to induce complications. Also leaving the apex in place,
can lead to later inflammation around the implant, when there are still bacteria present
in the apical delta of the remaining root apex.
Another aspect is that this technique can only be applied if the failing tooth has not
been extracted yet. No deep probing depths must be present at the time of implantation,
and increased mobility of the failing tooth should not occur or be accepted. Although
minor cracks in the buccal dentine can be removed and do not pose an obstacle, significant
fractures of the complete buccal dentine or bone wall are unacceptable for the socket
shield technique.
In conclusion, the socket shield technique can help implant placement in the esthetic
zone. The last decade has shown the establishment of promising scientific results and
a worldwide clinical routine. Currently, increasing emphasis is placed on the fact that
besides the esthetic results, the patient's morbidity is kept very low. Since the technique
is technically demanding and carries a residual risk inside caused by the dentine shield,
the technique should only be used in esthetically relevant areas. Other immediate
implantation techniques are described in the mouth's remaining areas, where they should
be the preferred choice of treatment.
68
CLINICAL RELEVANCE
MANY DIFFERENT DELAYED AND IMMEDIATE IMPLANTATION
TECHNIQUES HAVE BEEN RESEARCHED for tooth replacement in the upper
anterior jaw. Although good esthetic results can be expected, the treatment
duration as well as patient morbidity is still high owing to prolonged treatment
times and multiple surgeries or surgical sites.
By leaving the buccal piece of the root of the failing tooth in place, the
otherwise expected post-extractional resorption and remodeling processes are not
initiated. The socket shield technique has consequentially shown to completely
prevent soft and hard tissue alterations after immediate implantation with open
healing. At the same time, it reduces treatment time and patient morbidity to one
single surgery and one surgical site.
Abadzhiev M, Nenkov P, Velcheva P. (2014) Braut V, Bornstein MM, Belser U, Buser D. (2011) Glocker M, Attin T, Schmidlin P. (2014). Ridge
Conventional immediate implant placement and Thickness of the anterior maxillary facial bone wall. preservation with modified “socket-shield”
immediate placement with socket-shield technique– A retrospective radiographic study using cone beam technique: A methodological case series. Dentistry
which is better. International Journal of Clinical computed tomography. International Journal of Journal 2, 11-21.
Medicine Research 1, 176-180. Periodontics and Restorative Dentistry 31, 125-131. Gluckman H, Salama M, Du Toit J. (2016) Partial
Abd-Elrahman A, Shaheen M, Askar N, Atef M. (2020) Buser D, Chappuis V, Belser UC, Chen S. (2017) Implant Extraction Therapies (PET) Part 1: maintaining
Socket shield technique vs conventional immediate placement post extraction in esthetic single tooth alveolar ridge contour at pontic and immediate
implant placement with immediate temporization. implant sites. International Journal of Periodontics
sites: when immediate, when early, when late?
Randomized clinical trial. Clinical Implant Dentistry and Restorative Dentistry 36, 681-687.
Periodontology 2000 73, 84-102.
and Related Research 22, 602-611.
Buser D, Weber HP, Lang NP. (1990) Tissue integration Gluckman H, Salama M, Du Toit J. (2018). A
Araújo MG, Sukekava F, Wennstrom JL, Lindhe J. (2005) retrospective evaluation of 128 socket-shield cases
Ridge alterations following implant placement in of non-submerged implants. l-year results of a
prospective study with 100 ITI hollow-cylinder in the esthetic zone and posterior sites: Partial
fresh extraction sockets: an experimental study in extraction therapy with up to 4 years follow-up.
the dog. Journal of Clinical Periodontology 32, 645- and hollow-screw implants. Clinical Oral Implants
Clinical Implant Dentistry and Related Research 20,
652. Research 1, 33-40.
122-129.
Aslan S. (2018) Improved volume and contour stability Caiazzo A, Brugnami F, Mehra P. (2013) Buccal plate
Guyer SE. (1975) Selectively retained vital roots for
with thin socket-shield preparation in immediate preservation with immediate post-extraction implant
partial support of overdentures: A patient report.
implant placement and provisionalization in the placement and provisionalization: Preliminary results
Journal of Prosthetic Dentistry 33, 258-263.
esthetic zone. International Journal of Esthetic of a new technique. International Journal of Oral
Dentistry 13, 172-183. and Maxillofacial Surgery 42, 666-670. Han CH, Park KB, Mangano FG. (2018). The Modified
Baeumer D, Zuhr O, Rebele S, Hurzeler M. (2017) Socket Shield Technique. Journal of Craniofacial
Cherel F, Etienne D. (2014) Papilla preservation between Surgery 29, 2247-2254.
Socket Shield Technique for immediate implant
two implants: a modified socket-shield technique
placement - clinical, radiographic and volumetric Hinze M, Janousch R, Goldhahn S, Schlee M. (2018)
to maintain the scalloped anatomy? A case report.
data after 5 years. Clinical Oral Implants Research Volumetric alterations around single-tooth implants
Quintessence International 45, 23-30.
28, 1450-1458. using the socket-shield technique: preliminary
Baeumer D, Zuhr O, Rebele S, Schneider D, Schupbach P, Da Rosa JC, Rosa AC, da Rosa DM, Zardo CM. results of a prospective case series. International
Hurzeler M. (2013) The socket-shield technique: first (2013) Immediate Dentoalveolar Restoration of Journal of Esthetic Dentistry 13, 146-170.
histological, clinical, and volumetrical observations compromised sockets: A novel technique. The
Gluckman H, Du Toit J, Salama M. (2015) Guided
after separation of the buccal tooth segment: A European Journal of Esthetic Dentistry 8, 432-443.
bone regeneration of a fenestration complication
pilot study. Clinical Implant Dentistry and Related De Oliveira Rosa ACP, da Rosa JCM, Dias Pereira LAV, at immediate implant placement simultaneous to
Research 17, 71-82.
Eduardo Francischone C, Sotto-Maior BS. (2016) the socket-shield technique. International Dentistry
Bjork A. (1968) The use of metallic implants in the study Guidelines for selecting the implant diameter during - African Edition 5, 58-66.
of facial growth in children: method and application. immediate implant placement of a fresh extraction
American Journal of Physical Anthropology 29, Huerzeler MB, Zuhr O, Schupbach P, Rebele SF,
socket: A case series. International Journal of Emmanouilidis N, Fickl S. (2010). The socket-shield
243-254. Periodontics and Restorative Dentistry 36, 401-407. technique: a proof-of-principle report. Journal of
Bjork A, Skieller V. (1977) Growth of the maxilla in Clinical Periodontology 37, 855-862.
Esposito M, Maghaireh H, Grusovin MG, Ziounas I,
three dimensions as revealed radiographically by the
Worthington HV (2012). Soft tissue management Iseri H, Solow B. (1995). Average surface remodeling
implant method. British Journal of Orthodontics 4,
53-64. for dental implants: what are the most effective of the maxillary base and the orbital floor in female
techniques? A Cochrane systematic review. subjects from 8 to 25 years. An implant study.
Bramanti E, Norcia A, Cicciù M, Matacena G, Cervino European Journal of Oral Implantology 5, 221-238. American Journal of Orthodontics and Dentofacial
G, Troiano G, Zhurakivska K, Laino L. (2018)
Furhauser R, Florescu D, Benesch T, Haas R, Mailath G, Orthopedics 107, 48-57.
Postextraction dental implant in the aesthetic
zone, socket shield technique versus conventional Watzek G. (2005) Evaluation of soft tissue around John MT. (2018). Health Outcomes Reported by Dental
protocol. Journal of Craniofacial Surgery 29, 1037- single-tooth implant crowns: The pink esthetic score. Patients. Journal of Evidence Based Dental Practice
1041. Clinical Oral Implants Research 16, 639-644. 18, 332-335.
69
Kan JYK, Rungcharassaeng K. (2013) Proximal Socket Noelken R, Moergel M, Kunkel M, Wagner W. (2018) Siormpas KD, Mitsias ME, Kotsakis GA, Tawil I, Pikos
Shield for Interimplant Papilla Preservation in Immediate and flapless implant insertion and MA, Mangano FG. (2018) The root membrane
the Esthetic Zone. The International Journal of provisionalization using autogenous bone grafts technique: A retrospective clinical study with up to
Periodontics and Restorative Dentistry 33, e24-e31. in the esthetic zone: 5-year results. Clinical Oral 10 years of follow-up. Implant Dentistry 27, 564-
Kan JYK, Rungcharassaeng K, Deflorian M, Weinstein Implants Research 29, 320-327. 574.
T, Wang HL, Testori T. (2018) Immediate implant Petsch M, Spies B, Kohal RJ. (2017) Socket Shield Slagter KW, Meijer HJA, Hentenaar DFM, Vissink A,
placement and provisionalization of maxillary technique for implant placement in the esthetic Raghoebar GM. (2021) Immediate single-tooth
anterior single implants. Periodontology 2000 77, zone: A case report. International Journal of implant placement with simultaneous bone
197-212. Periodontics and Restorative Dentistry 37, 853-860. augmentation versus delayed implant placement
Khzam N, Arora H, Kim P, Fisher A, Mattheos N, after alveolar ridge preservation in bony defect
Raghoebar GM, Slater JJ, Hartog L, Meijer HJ, Vissink
Ivanovski S. (2015) Systematic review of soft sites in the esthetic region: A 5-year randomized
A. (2009) Comparison of procedures for immediate
tissue alterations and esthetic outcomes following controlled trial. Journal of Periodontology 48, 272-
reconstruction of large osseous defects resulting
immediate implant placement and restoration of 283.
from removal of a single tooth to prepare for
single implants in the anterior maxilla. Journal of insertion of an endosseous implant after healing. Staehler P, Abraha SM, Bastos J, Zuhr O, Hürzeler M.
Periodontology 86, 1321-1330. International Journal of Oral and Maxillofacial (2020) The socket-shield technique: A step-by-step
Kumar PR, Kher U. (2018) Shield the socket: Procedure, Surgery 38, 736-743. protocol after 12 years of experience. International
case report and classification. Journal of Indian Journal of Esthetic Dentistry 15, 288-305.
Roe P, Kan JYK, Rungcharassaeng K. (2017) Residual
Society of Periodontology 22, 266-272.
root preparation for socket-shield procedures: A Sun C, Zhao J, Liu Z, Tan L, Huang Y, Zhao L, Tao H.
Lee CT, Chiu TS, Chuang SK, Tarnow D, Stoupel J. facial window approach. International Journal of (2020) Comparing conventional flap-less immediate
(2014) Alterations of the bone dimension following Esthetic Dentistry 12, 324-335. implantation and socket-shield technique for
immediate implant placement into extraction esthetic and clinical outcomes: A randomized clinical
Salama M, Ishikawa T, Salama H, Funato A, Garber
socket: Systematic review and meta-analysis. Journal study. Clinical Oral Implants Research 31, 181-191.
D. (2007) Advantages of the root submergence
of Clinical Periodontology 41, 914-926.
technique for pontic site development in Troiano M, Benincasa M, Sánchez P, Calvo-Guirado JL.
Lin GH, Chan HL, Wang HL. (2014) Effects of currently esthetic implant therapy. International Journal of (2014) Bundle bone preservation with Root-T-Belt:
available surgical and restorative interventions on Periodontics & Restorative Dentistry 27, 520-527. Case study. Annals of Oral & Maxillofacial Surgery
reducing midfacial mucosal recession of immediately 2, 1-7.
placed single-tooth implants: A systematic review. Schropp L, Isidor F, Kostopoulos L, Wenzel A. (2004)
Journal of Periodontology 85, 92-102. Patient experience of, and satisfaction with, vn Nimwegen WG, Raghoebar GM, Zuiderveld EG, Jung
delayed-immediate vs. delayed single-tooth implant RE, Meijer HJ, Mühlemann S. (2018) Immediate
Mahajan T, Massey NS, Bajwa W. (2015) Socket shield placement. Clinical Oral Implants Research 15, 498- placement and provisionalization of implants in the
technique. Indian Dental Journal 7, 31-34. 503. aesthetic zone with or without a connective tissue
Mitsias ME, Siormpas KD, Kontsiotou-Siormpa E, Prasad graft: A 1-year randomized controlled trial and
Schwimer C, Pette GA, Gluckman H, Salama M, Du
H, Garber D, Kotsakis GA. (2015) A step-by-step volumetric study. Clinical Oral Implants Research 29,
Toit J. (2018) Human histologic evidence of new
description of pdl-mediated ridge preservation for 671-678.
bone formation and osseointegration between
immediate implant rehabilitation in the esthetic
root dentin (unplanned socket-shield) and dental Welker WA, Jividen GJ, Kramer DC. (1978) Preventive
region. International Journal of Periodontics and
implant: Case report. The International Journal of prosthodontics—Mucosal coverage of roots. Journal
Restorative Dentistry 35, 835-841.
Oral and Maxillofacial Implants 33, e19-e23. of Prosthetic Dentistry 40, 619-621.
Mitsias ME, Siormpas KD, Kotsakis GA, Ganz SD,
Mangano C, Iezzi G. (2017) The root membrane Seyssens L, De Lat L, Cosyn J. (2021) Immediate implant Zufia J, Blasi G, Gomez-Meda R, Blasi A. (2019) The
technique: Human histologic evidence after five placement with or without connective tissue graft: four-layer graft technique, a hard and soft tissue
years of function. BioMed Research International A systematic review and meta-analysis. Journal of graft from the tuberosity in one piece. Journal of
2017: 7269467. Clinical Periodontology 48, 284-301. Esthetic and Restorative Dentistry 31, 304-310.
Mittal H, John MT, Sekulic S, Theis-Mahon N, Rener-Sitar Seyssens L, Eghbali A, Cosyn J. (2020) A 10-year Zuhr O, Staehler P, Huerzeler M. (2020) Complication
K. (2019) Patient-reported outcome measures for prospective study on single immediate implants. management of a socket shield case after 6 years
adult dental patients: A systematic review. Journal of Journal of Clinical Periodontology 47, 1248-1258. of function. International Journal of Periodontics &
Evidence-Based Dental Practice 19, 53-70. Restorative Dentistry 40, 408-415.
Siormpas KD, Mitsias ME, Kontsiotou-Siormpa E,
Mourya A, Mishra SK, Gaddale R, Chowdhary R. (2019) Garber D, Kotsakis GA. (2014) Immediate implant
Socket-shield technique for implant placement to placement in the esthetic zone utilizing the root-
stabilize the facial gingival and osseous architecture: membrane technique: Clinical results up to 5 years
A systematic review. Journal of Investigative and postloading. The International Journal of Oral and
Clinical Dentistry 10, e12449. Maxillofacial Implants 29, 1397-1405.
70
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74
Clinical case
THE INFLUENCE OF CAF AND CTG

ON IMMEDIATE IMPLANT PLACEMENT.
A MODIFIED CORONAL ADVANCED FLAP IN COMBINATION WITH CONNECTIVE TISSUE GRAFT IN
IMMEDIATE POST-EXTRACTION IMPLANTS.
MASSIMO DE SANCTIS, DAVIDE GUGLIELMI.
Massimo de Sanctis. Prof. MD, MSc - Vita Salute

San Raffaele University – Milan. SUMMARY
Davide Guglielmi. Dr. DDM, MSc - Vita Salute
San Raffaele University – Milan. IMMEDIATE IMPLANT PLACEMENT (IIP) is considered a complex surgical procedure
that should be performed only in case of ideal anatomic conditions. (Buser et al. 2004).
In the decision-making process, clinicians should pay particular attention to the
presence of infection, inability to achieve primary stability, soft tissue phenotype,
aesthetic demands and systemic conditions (Tonetti et al. 2019).
Although IIP may bring tangible benefits to patients due to shorter treatment time,
it may present also post-surgical complications and clinicians should be aware that it
carries an additional risk of early implant loss (4% excess implant loss) as compared to the
delayed protocol as well as impaired esthetics with a higher chance of mid facial recession
(Cosyn et al. 2019).
The use of connective tissue grafts (CTG) in combination with immediate implants
has shown to decrease recession of soft tissue by increasing the thickness and thus,
compensating the physiological tissue loss (Sanz-Martin et al. 2018).
The present case report describes a technique used in mucogingival surgery: the
multiple coronally advanced flap procedure (MCAF), as proposed by Zucchelli and
de Sanctis (2000), in combination with a connective tissue graft and insertion of an
immediate post-extraction implant c (Zucchelli and de Sanctis 2000).
Placement of a CTG concurrent with IIP may contribute to the stability of the
Correspondence to: gingival level and the augmentation of soft tissue contours. This case report describes
Davide Guglielmi the assessment of volumetric hard and soft tissue changes six months (6M) after IIP with
dr.davideguglielmi@gmail.com CTG.
75 Massimo de Sanctis Davide Guglielmi

INTRODUCTION
IT IS WELL KNOWN that following the extraction of a tooth, severe hard and soft tissue
alterations may take place at the socket site (Pietrokovski and Massler 1967; Discepoli
et al. 2013), resulting in a subsequent reduction of both vertical and horizontal ridge
dimensions (Araujo and Lindhe 2005; Tan et al. 2012).
Following the partial resorption of the buccal wall of a post-extraction socket, marked
alterations of the soft tissue contour can occur, with loss of volume of both hard and
soft tissues in the horizontal dimension of around 5–7 mm within the first 12 months,
corresponding to about 50% of the original width of the alveolar crest (Schropp et al.
2003).
Preclinical and clinical evidence indicated that immediate positioning of the implant
does not prevent the three-dimensional modification of the alveolus induced by tooth
extraction (Vignoletti et al. 2009; Clementini et al. 2019; Cosyn et al. 2019).
Changes in the soft tissue and the subsequent reduction in both thickness and width,
may have a negative impact on the esthetic of the prosthetic restoration and in the
maintenance of optimal plaque control (Chen et al. 2009; Cosyn et al. 2012).
Although the relative contribution of the soft and hard tissues to the total volume
and their mutual interplay are not completely understood, recent volumetric analysis
highlighted that soft tissue thickness in some circumstances, can increase following
tooth extraction in sites with a thin phenotype, to compensate for the vestibular bone
deficiencies and therefore allowing the maintenance of the volume at 8 weeks of healing
(Chappuis et al. 2015).
Nevertheless, this biologic process cannot predictably prevent volumetric changes in
the extraction area. The reduction of soft tissue contour, even in presence of an adequate
bone dimension for the insertion of an implant, may greatly affect the aesthetic outcome of
the prosthetic reconstruction.
Over the past 20 years, several surgical procedures, have been proposed, aiming to the
maintenance of the existing soft and hard tissues (Hämmerle et al. 2012; Clementini et al
2019).
However, systematic reviews on the performance of specific ARP treatment modalities
compared to the natural healing of the alveolus, produce very limited information to the
clinician in the decision-making process (Willenbacher et al. 2016).
Nevertheless, everyday more evidence arises indicating that soft tissue management
around implants is of outmost importance in creating an ideal situation for the restorative
work and for maintenance of a state of health.
One of the most frequent complications in fact is the occurrence of marginal tissue
recession and loss of the buccal maxillary contour in about 20% of patients (Vignoletti and
Sanz 2014).
Many surgical techniques have been proposed to increase soft tissue thickness, as well
as keratinized tissue, before implant placement, at the time of implant positioning, or
after the prosthetic reconstruction (Cairo et al. 2019; Chackartchi et al. 2019; Giannobile
et al. 2018).
The placement of a connective tissue graft in association with IIP may contribute to
the stability of gingival level and the augmentation of soft tissue contours. (D’Elia et al.
2017).
However, it is unknown whether CTG can compensate for bone resorption and
maintain the buccal bone plate over time (Tavelli et al 2021).
The use of a connective tissue graft has been proposed together with the incision of a
flap, or via the production of a pouch between bone and existing soft tissue (Thoma et al.
2014).
This case report describes the use of an envelope coronally advanced flap with a
connective tissue graft in combination with immediate implant placement in a patient
with esthetic demands (Zucchelli and de Sanctis 2000).
76
Massimo de Sanctis, The influence of CAF and CTG on immediate implant placement. A modified coronal advanced flap in Clinical case
Davide Guglielmi combination with connective tissue graft in immediate post-extraction implants
Figure 1.
Buccal and occlusal clinical views and periapical x ray of the second quadrant.
Figure 2.
Measurements before extraction. The evaluation of the buccal soft tissue contour was performed by matching
STL files resulting from digital intra-oral impressions. An assessment of buccal bone dimension resulting from
DICOM files of the CBCT.
PRESENTATION OF THE CASE

A 38-YEARS-OLD WOMAN was referred to the Department of Dentistry at San Raffaele
Hospital with a history of trauma. She fractured the maxillary first left premolar.
Intra-oral clinical and radiographic examination revealed a vertical root fracture line
below the cemento-enamel junction of an endodontically treated tooth (Figure 1). Figure 3.
A CBCT was performed and revealed an adequate alveolar bone thickness and the Flap Design. Incisions in the interdental areas
oriented in an oblique way towards the fractured
absence of periapical pathology.
tooth.
Therefore, it was decided to extract the fractured tooth and immediately place an
implant with an adjunct of a connective tissue graft (Figure 2).
Following local anesthesia, a buccal envelope flap was performed according to the
design of the multiple coronally advanced flap proposed by Zucchelli and de Sanctis. The
flap incisions extended to one adjacent tooth on the mesial and distal of the tooth to be
extracted allowing the coronal displacement of the flap (Figure 3).
77
Figure 4.
Oblique incisions: the surgical blade is parallel to the long axis of the teeth allowing a split-thickness dissection
of the surgical papillae.
Figure 5.
Buccal and occlusal view of the post-extraction socket.
The flap was elevated according to a split-full-split thickness approach in the coronal-
apical direction. Surgical papillae were oriented toward the center of rotation of the
flap, that was the site of implant positioning. A complete description of the technique is
presented in the original article (Zucchelli and de Sanctis 2000) (Figure 4).
The tooth was gently luxated using periotomes and then extracted using a small
dental elevator, paying particular attention to avoid possible damages to the vestibular
cortical bone plate. The socket was inspected and explored with a probe and then irrigated
with saline (Figure 5).
The osteotomy was prepared with the surgical drill of the Winsix surgical kit (Biosafin)
at 1200 rpm under saline irrigation. A Winsix KE (Biosafin) implant was immediately
inserted and a healing screw was placed. The implant was positioned taking maximum
care to insert it slightly palatal to the center of the alveolus in order to create a gap
between the implant surface and the buccal bone crest (Kan et al. 2018) (Figure 6).
The full thickness elevation performed was limited to the first 5 mm of the cortical
bone, to include the periosteum in the flap, thus modulating the thickness to the aim
of increasing soft tissue marginal thickness and post-surgical stability. The apical split
thickness was directed to maintain the periosteum protection of the cortical bone while
at the same time detaching all muscle insertions to allow for maximal mobility of the flap
in coronal direction. Both a deep and superficial split thickness incisions were performed
(Figure 7).
78
Figure 6.
Buccal and occlusal view at implant insertion.
Figure 7.
Superficial split thickness incisions. The blade is kept parallel to the flap in order to separate muscles from
alveolar mucosa.
Figure 8. Figure 9.
The anatomic interdental papillae are de-epithelialized. Connective Tissue Graft harvested from the palate
de-epithelialized using a scalpel nr 15.
The preserved tissue of the mesial and distal anatomic papillae were de-epithelialized
to create connective tissue vascular beds, to support the flap after suturing (Figure 8).
A free gingival graft was harvested from the posterior palate and de-epithelialized
extra orally (Figure 9).
79
Figure 10.
Positioning and suturing of the connective tissue graft.
Figure 11.
Buccal, occlusal and lateral views of flap closure.
CTG was consequently applied buccally at implant site and fixed with single
interrupted sutures to the base of the anatomical de-epithelialized papillae.
The apico-coronal dimension of the vestibular connective tissue graft was determined
in order to cover the gap between the implant surface and the part of the buccal bone wall
deprived by the periosteum (Figure 10).
Sling sutures were performed to accomplish an accurate adaptation of the buccal flap
on the implant surface and to stabilize every single surgical papillae over the interdental
connective tissue bed (Figure 11).
Following surgery the patient was instructed to rinse twice a day with 0.2%
chlorhexidine and to avoid brushing the area of interest for 2 weeks.
A post-operative drug therapy was prescribed, which included painkillers and
antibiotics for six days.
The post-surgical healing was uneventful.
The sutures were removed at 1 week and 2 weeks after surgery.
A temporary Maryland bridge was delivered to the patient and follow-up evaluations
were performed at 7, 14, 30, 90, 180 days after surgery (Figure 12).
The definitive cemented restoration was delivered 6 months after clinical and
radiographic measurements.
An assessment of buccal bone changes was performed by matching DICOM files of
the CBCTs taken before tooth extraction and at 6M. The evaluation of buccal soft tissue
contour changes was performed by matching STL files resulting from digital intra-oral
impressions taken before tooth extraction and at 6M (Figure 13).
80
Figure 12.
Clinical situation 1 month after surgery with provisional restoration (Maryland Bridge).
Figure 13.
6 months measurements.
An assessment of buccal bone changes was performed by matching DICOM files of the CBCTs taken before tooth extraction and at 6M. The evaluation of buccal soft tissue
contour changes was performed by matching STL files resulting from digital intra-oral impressions taken before tooth extraction and at 6M.
First column: Evaluation of horizontal and vertical buccal bone loss; Second column: Evaluation of buccal soft tissue contour changes; Third column: Evaluation of (a)
baseline and (b) 6 month follow-up soft tissue thickness.
81
Horizontal and vertical bucal bone loss (mm)
HBBL 1 HBBL 2 HBBL 3 HBBL 4 HBBL 5 VBBL
1.98 1.92 1.35 1.28 1.37 0.97
Horizontal buccal soft contour changes (mm)
TC 1 TC 2 TC 3 TC 4 TC 5
0.46 0.41 0.4 0.37 0.06
Buccal soft tissue thickness (mm)

Figure 15.
GT 1 GT 2 GT 3 GT 4 GT 5
Clinical and radiographic evaluation 18 months after surgery with definitive restoration.
BS 0.83 1.15 0.64 0.52 0.57
6M 3.78 4.95 5.72 5.63 3.73
Figure 14.
Tables describe data from matching DICOM files
of the CBCTs and STL files.
Figure 16.
Lateral and occlusal views 18 months after surgery with definitive restoration.
RESULTS
AFTER 6M, there was a horizontal buccal bone loss ranging between 1.35 and 1.98
mm. In contrast, there was an increase of horizontal buccal soft tissue contour ranging
between 0.06 and 0.46 mm and the soft tissue thickness, 2 mm below the gingival margin,
increased 4 mm (Figure 14).
The 18 M results showed a complete preservation of the interproximal papillae height,
and the maintenance of the buccal soft tissue profiles.
The final prosthetic crowns presented a natural emergence profile that mimicked the
ones of the adjacent teeth.
The data from the superimposition of the two DICOM files demonstrated that the
insertion of a CTG under the flap allowed to maintain the original soft tissue thickness
and to obtain a tissue contour matching the adjacent gingival architecture. Radiographs
revealed stability of marginal bone levels at implant sites and at the adjacent teeth.
The implant demonstrated healthy clinical conditions with pockets <4 mm and
bleeding on probing ≤25% (Figures 15 and 16).
82
DISCUSSION
SOFT TISSUE MANAGEMENT AROUND IMPLANTS has become a topic of growing
interest in implant dentistry, as a response to the increasing patient aesthetic demands.
In the present case report a surgical approach for aesthetic implant surgery was
utilized.
The multiple coronally advanced flap (Zucchelli and de Sanctis 2000) has been
proposed for treatment of multiple recession defects in teeth and has been demonstrated
to be a very effective surgical technique in obtaining complete root coverage and to
maintain marginal stability over time (Sanz and Simion 2014).
The same technique was proposed by the same authors for the treatment of intrabony
periodontal defects in patients with esthetic demands (Zucchelli and de Sanctis 2008)
In this clinical case, the MCAF technique has been successfully applied in combination
with a connective tissue graft in an immediate implant insertion to compensate the
dimensional changes of soft tissue contour following tooth extraction.
Some clinical and biological advantages can derive by the use of this flap design.
The absence of vertical releasing incisions avoids the possibility of scar or keloid tissue
during the healing phases, at the same time improving the vascular supply of the flap.
Also, the possibility of the coronal positioning of the flap, free from any tension, can
improve the positioning of the connective graft, while the coronal position will counteract
the post-surgical marginal shrinkage and at the same time will allow to treat recession on
the adjacent teeth.
The “tissue modulation” effect derived by the split-full-split elevation, will produce
several advantages: inspection of the coronal portion of the cortical bone, protection
of the apical part of the buccal bone and at the same time, provide freedom for flap
advancement.
Also, with the proposed incision, the body of the anatomical papilla is maintained
intact, giving on one side support to the flap once sutured and on the other maintaining
the esthetic dimension of interdental soft tissues, reducing the risk for papilla contraction.
The risk for post-surgical soft tissue contraction may be a very serious complication in
implant sites and a common occurrence following immediate tooth replacement (Kan et al.
2009; De Rouck 2009).
A recent systematic review (Lee et al. 2016) reported that placement of a connective
tissue graft at the same time as an immediate implant, may contribute to the stability of
the gingival level and the augmentation of soft tissue contours.
Furthermore, the use of a CTG has been recently compared with guided bone
regeneration (GBR) concomitant to delayed implant placement. Results demonstrated
that both GBR and CTG were equally effective to re-establish convexity at the buccal
aspect of single implants in the short term (D’Elia et al. 2017).
The fate of bone resorption and remodeling seems not to be influenced also in case
where the implant is inserted immediately after the extraction. The resorption of the
alveolar buccal and lingual wall, in fact, occurs also in sites with implant insertion
(Botticelli et al. 2004; Sanz et al. 2010).
In the present case report, data were collected from matching DICOM of the CBCTs
and STL files resulting from digital intra-oral impressions before tooth extraction (T0) and
after 6 M (T1).
From the comparison of the results before tooth extraction (T0) with ones after 6
M (T1) it was observed a horizontal buccal bone loss ranging from 1.35 to 1.98 mm
(Horizontal Buccal Bone Loss - HBBL - Figures 13 and 14).
83
These results can be explained by the fact that an increase in the thickness of the
soft tissues, could increase the stability of the bone crest influencing the process of bone
remodeling (Linkevicius et al. 2009; Puisys and Linkevicius 2015).
Comparing data obtained by STL files from digital intraoral impression before tooth
extraction (T0) with data after 6 M (T1) it was observed an increase of horizontal buccal
soft tissue contour ranging from 0.06 to 0.46 mm, that is substantially maintaining the
pre-surgical dimension (Buccal Soft Tissues Contour Changes - TC - Figures 13 and 14).
Moreover, at 3 mm below the gingival margin soft tissue was increased 5.08 mm (0.64
mm at T0; 5.72 mm at T1).
This change can be explained by the presence of the connective tissue graft and also
by the fact that the soft tissue thickness may increase compensating partly the dimension
of bone resorption (Chappuis et al. 2015) (Gingival Thickness at 3 mm - (GT3) Figures 13
and 14).
The results of this case report suggest that the use of a CTG in combination with
a Modified Coronal Advanced Flap, has led to a significantly greater increase in both,
thickness and width, of the keratinized tissue at the vestibular level, in comparison to
the data from the literature (Lee et al. 2016; Clementini 2020), with benefit to the final
esthetic of the prosthetic reconstruction.
CONCLUSION
THIS CASE REPORT showed that the use of the multiple coronally advanced flap`with
the adjunct of CTG, in immediate implant placement, can provide excellent results, by
establishing and maintaining an adequate soft tissue contour in aesthetic area.
Within the limits of this case report it can be concluded that the adjunction of a
CTG during immediate implant placement may compensate the soft tissue dimensional
alteration that usually occurs after tooth extraction, maintaining or increasing the buccal
volume over time. Moreover, an increase in soft tissue thickness may be beneficial for the
biological, functional and aesthetic stability of the peri-implant mucosal margin.
CLINICAL RELEVANCE
THE USE OF AN IMMEDIATE POST EXTRACTION TECHNIQUE may
produce some inconvenience especially when treating anterior areas of the
mouth. The proposed technique may greatly reduce volume reduction in the
extraction area and improve marginal tissue stability around the implant.
Within the limits of this case report it can be concluded that the utilization of
multiple coronally advanced flap in adjunct of a CTG during immediate implant
placement may compensate the soft tissue dimensional alterations, that usually
occur after tooth extraction, by maintaining or increasing the buccal volume over
time.
84
Araujo MG, Lindhe J. (2005) Dimensional ridge De Rouck T, Collys K, Wyn I, Cosyn J. (2009) Instant Sanz-Martín I, Encalada C, Sanz-Sánchez I, Aracil
alterations following tooth extraction. An provisionalization of immediate single-tooth implants J, Sanz M. (2018) Soft tissue augmentation at
experimental study in the dog. Journal of Clinical is essential to optimize esthetic treatment outcome. immediate implants using a novel xenogeneic
Periodontology 32, 212-218. Clinical Oral Implants Research 20, 566-570. collagen matrix in conjunction with immediate
Botticelli D, Berglundh T, Lindhe J. (2004) Hard-tissue Discepoli N, Vignoletti F, Laino L, de Sanctis M, Munoz F, provisional restorations: A prospective case series.
alterations following immediate implant placement Sanz M. (2013) Early healing of the alveolar process Clinical Implant Dentistry and Related Research 21,
in extraction sites. Journal of Clinical Periodontology after tooth extraction. An experimental study in the 145-153.
31, 820-828. beagledog. Journal of Clinical Periodontology 40, Schropp L, Wenzel A, Kostopoulos L, Karring T. (2003)
Buser D, Martin W, Belser UC. (2004) Optimizing 638-644. Bone healing and soft tissue contour changes
esthetics for implant restorations in the anterior Giannobile WV, Jung RE, Schwarz F. (2018) Groups of following single-tooth extraction: A clinical and
maxilla: anatomic and surgical considerations. the 2nd Osteology Foundation Consensus Meeting. radiographic 12-month prospective study. The
The International Journal of Oral and Maxillofacial Evidence-based knowledge on the aesthetics and International Journal of Periodontics and Restorative
Implants 19 Suppl, 43-61. maintenance of peri-implant soft tissues: Osteology Dentistry 23, 313-323.
Cairo F, Barbato L, Selvaggi F, Baielli MG, Piattelli A, Foundation Consensus Report Part 1-Effects Tan W, Wong TL, Wong MC, Lang NP. (2012) A
Chambrone L. (2019) Surgical procedures for soft of soft tissue augmentation procedures on the systematic review of postextractional alveolar hard
tissue augmentation at implant sites. A systematic maintenance of peri-implant soft tissue health. and soft tissue dimensional changes in humans.
review and meta-analysis of randomized controlled Clinical Oral Implants Research 29 Suppl 15, 7-10. Clinical Oral Implants Research 23 Suppl 5, 1-21.
trials. Clinical Implant Dentistry and Related Research Hämmerle CH, Araújo MG, Simion M. (2012) Osteology Tavelli L, Barootchi S, Ávila-Ortiz G, Urban IA, Giannobile
21, 1262-1270. Consensus Group 2011. Evidence-based knowledge WV, Wang HL. (2021) Peri-implant soft tissue
Chackartchi T, Romanos GE, Sculean A. (2019) Soft on the biology and treatment of extraction sockets. phenotype modification and its impact on peri-
tissue-related complications and management Clinical Oral Implants Research 23 Suppl 5, 80-82. implant health: A systematic review and network
around dental implants. Periodontology 2000 81, Kan JYK, Rungcharassaeng K, Deflorian M, Weinstein meta-analysis. Journal of Periodontology 92, 21-44.
124-138. T, Wang HL, Testori T. (2018) Immediate implant Thoma DS, Buranawat B, Hämmerle CH, Held U, Jung
Chappuis V, Engel O, Reyes M, Shahim K, Nolte LP, placement and provisionalization of maxillary RE. (2014) Efficacy of soft tissue augmentation
Buser D. (2015) Ridge alterations post- extraction in anterior single implants. Periodontology 2000 around dental implants and in partially edentulous
the esthetic zone: A 3D analysis with CBCT. J Dent 77,197-212. areas: a systematic review. Journal of Clinical
Res 92 Suppl 12, S195-S201. Kan JYK, Rungcharassaeng K, Morimoto T, Lozada Periodontology 41 Suppl 15, S77-S91.
Chen ST, Buser D. (2009) Clinical and esthetic outcomes J. (2009) Facial gingival tissue stability after Tonetti MS, Jung RE, Ávila-Ortiz G, Blanco J, Cosyn
of implants placed in postextraction sites. The connective tissue graft with single immediate tooth J, Fickl S, Figuero E, Goldstein M, Graziani F,
International Journal of Oral and Maxillofacial replacement in the esthetic zone: Consecutive case Madianos P, Molina A, Nart J, Salvi GE, Sanz-Martín
Implants 24 Suppl, 186-217. report. Journal of Oral and Maxillofacial Surgery 67, I, Thoma D, Van Assche N, Vignoletti F. (2019)
40-48. Management of the extraction socket and timing
Clementini M, Agostinelli A, Castelluzzo W, Cugnata of implant placement: Consensus report and clinical
F, Vignoletti F, De Sanctis M. (2019) The effect of Lee CT, TaoCY, Stoupel J. (2016) The effect of
subepithelial connective tissue graft placement recommendations of group 3 of the XV European
immediate implant placement on alveolar ridge Workshop in Periodontology. Journal of Clinical
preservation compared to spontaneous healing on esthetic outcomes after immediate implant
placement: Systematic review. Journal of Periodontology 46 Suppl 21, 183-194.
after tooth extraction: Radiographic results of
a randomized controlled clinical trial. Journal of Periodontology 87, 156-167. Vignoletti F, De Sanctis M, Berglundh T, Abrahamsson
Clinical Periodontology 46, 776-786. Linkevicius T, Apse P, Grybauskas S, Puisys A. (2009) I, Sanz M. (2009) Early healing of implants placed
The influence of soft tissue thickness on crestal bone into fresh extraction sockets: an experimental study
Clementini M, Castelluzzo W, Ciaravino V, Agostinelli in the beagle dog. II: Ridge alterations. Journal of
A, Vignoletti F, Ambrosi A, De Sanctis M. (2020) The changes around implants: A 1-year prospective
controlled clinical trial. The International Journal of Clinical Periodontology 36, 688-697
effect of immediate implant placement on alveolar
ridge preservation compared to spontaneous Oral and Maxillofacial Implants 24, 712-719. Vignoletti F, Sanz M. (2014) Immediate implants at
healing after tooth extraction: Soft tissue findings Pietrokovski J, Massler M. (1967) Alveolar ridge fresh extraction sockets: From myth to reality.
from a randomized controlled clinical trial. Journal resorption following tooth extraction. Journal of Periodontology 2000 66, 132-152.
of Clinical Periodontology 47,1536-1546. Prosthetic Dentistry 17, 21-27. Willenbacher M, Al-Nawas B, Berres M, Kämmerer
Cosyn J, Hooghe N, De Bruyn H. (2012) A systematic Puisys, A, Linkevicius T. (2015) The influence of mucosal PW, Schiegnitz E. (2016) The effects of alveolar
review on the frequency of advanced recession tissue thickening on crestal bone stability around ridge preservation: A meta-analysis. Clinical Implant
following single immediate implant treatment. bone-level implants. A prospective controlled clinical Dentistry and Related Research 18,1248-1268.
Journal of Clinical Periodontology 39,582-589. trial. Clinical Oral Implants Research 26, 123-129. Zucchelli G, De Sanctis M. (2000) Treatment of Multiple
Cosyn J, De Lat L, Seyssens L, Doornewaard R, Sanz M, Simion M, Working Group 3 of the European Recession-Type Defects in Patients With Esthetic
Deschepper E, Vervaeke S. (2019) The effectiveness Workshop on Periodontology. (2014) Surgical Demands*. Journal of Periodontology 71, 1506-
of immediate implant placement for single techniques on periodontal plastic surgery and soft 1514.
tooth replacement compared to delayed implant tissue regeneration: Consensus Report of Group 3 Zucchelli G, De Sanctis M. (2008) A novel approach to
placement: A systematic review and meta-analysis. of the 10th European Workshop on Periodontology. minimizing gingival recession in the treatment of
Journal of Clinical Periodontology 46, 224-241. Journal of Clinical Periodontology 41 Suppl 15, vertical bony defects. Journal of Periodontology 79,
D'Elia C, Baldini N, Cagidiaco EF, Nofri G, Goracci C, S92-S97. 567-574.
de Sanctis M. (2017) Peri-implant soft tissue stability Sanz M, Cecchinato D, Ferrus J, Pjetursson EB, Lang
after single implant restorations using either guided NP, Lindhe J. (2010) A prospective, randomized-
bone regeneration or a connective tissue graft: A controlled clinical trial to evaluate bone preservation
randomized clinical trial. International Journal of using implants with different geometry placed
Periodontics and Restorative Dentistry 37, 413-421. into extraction sockets in the maxilla. Clinical Oral
Implants Research 21, 13-21.
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Clinical case
AN INNOVATIVE STRATEGY FOR

IMMEDIATE IMPLANT PLACEMENT
REHABILITATION IN MOLAR SITES:
THE SSA CONCEPT.
GARY FINELLE.
Gary Finelle. Lecturer in Advanced Graduate

Implant Dentistry Harvard School of Dental
Medicine, Boston, MA, USA; Private practice,
SUMMARY
Paris, France. MOLAR REPLACEMENT is the most frequent therapeutic modality in implant dentistry.
However, many different clincal protocols are proposed and utilized in order to maintain
volume stability after tooth extraction (including early placement, socket preservation
and immediate implant placement). From the patient´s perspective, immediate protocols
provide satisfying experience, but surgical manipulation for closure obtention may
generate invasiveness and unpredictability. In this perspective, the goal of this article is
to describe a clinical workflow combining immediate implant placement on molar sites
and prosthetic non invasive closure by the use of a customized healing abutment (SSA:
Sealing Socket abutment). Based on the SSA (sealing socket abutment) Concept, the
SSA Gingival Fit Abutment (Biotech Dental, France) is presented as a multi-functional
anatomical abutment that has been developed to offer a highly biocompatible interface,
integrate one time one abutment concept and allow for digital scanning.
INTRODUCTION
THE CLINICAL PROTOCOLS for implant placement and loading have substantially
Correspondence to: evolved since the initial concept described by Brånemark in the 80’s (Brånemark 1983).
Gary Finelle Over the years, the technical advancements in 3D imaging, and CAD softwares allow us
gary.finelle@dental7paris.com to plan, diagnose, and execute surgical procedures with higher precision and predictibility.
87 Gary Finelle
SSA – 3 TECHNIQUES
Figure 1.
SSA workflows: a) Pre-operatively Labside, combined with guided implant surgery (CAD-CAM, Digital); b) Per-
operatively, chairside, CAD / CAM milling system (CAD-CAM, Digital) 1; c) Per-operatively, chairside by adding
photopolymerisable increments of composite (Flowable composite, Conventionnal).
In this context, the immediate post-extraction implant placement has been

scientifically supported through numerous publication dealing with this clinical strategy
(Vignoletti and Sanz 2014). It is, now widely accepted, that conducted with respect to the
rules of a 3D positioning, this procedure can be predictably implemented. Since many
years, immediacy is routinely utilized in dental implant practices as it allows to reduce
number of surgeries, overall treatment time, and morbidity (Chen and Buser 2014; Bhola
et al. 2008).
In the recent years, Implant timing Type 1 (immediacy) in the esthetic zone, have
been presented as an attractive treatment (when conducted properly) alternative for the
patient as well as for the dentist for the clinical benefits it offers:
reduction of number of surgeries, reduction of overall treatment time and reduction of
morbidity.
In this region, (Immediate placement) is commonly associated with an immediate
provisional prosthesis as this socially involved site requires an esthetic temporary solution
(De Rouck et al. 2009; Chen et al. 2007).
Opposingly, in molar sites, the risk of failing osseointegration for an implant
undergoing extensive masticatory load is not worth the benefit of receiving restoration on
the day of the surgery.
Thus, although many studies reported similar implant survival rates when
implantation is performed immediately after extraction (98.8%) or on healed sites (99%) at
molar sites (Atieh 2010), hermetic primary closure around the healing abutment remains
the major challenge.
For this reason, several authors have proposed to utilize a customized anatomical
healing abutment (Akin 2016), also described as SSA (« Sealing Socket Abutment »)
(Finelle 2015; Finelle and Lee 2017).
The aim of the technique is to mimick the benefits of the transmucosal tissue
conditioning observed when immediate restoration is performed without taking the
mechanical risks of the micromovements on a NON osseointegrated implant.
Moreover, the SSA allows to perform a physical barrier and serves to:
- Seal Mechanically the surgical site following the outline of the extraction socket with
its anatomical design.
- Stabilize the blood clot in a confined and a favorable space for bone regeneration and
substitute material (Retzepi 2010).
- Develop an ideal prosthetic emergence profile modeled on the anatomy of the existing
tooth (Chu 2012).
Diverse manufacturing techniques (Figure 1) have been proposed previously, firstly
through digital ways which appeared as the more appropriate workflow. Subsequently, in
order to make this technique accessible to the greatest number of practitioners who are
not digitally equiped this customized healing abutment has been adapted for conventional
workflow with flowable composite.
88
Gary Finelle An innovative strategy for immediate implant placement rehabilitation in molar sites: the SSA concept Clinical case
To date, this customized healing abutment could be performed in different ways

(digitally and by so-called traditional chairside technique) (Knafo and Finelle 2020).
The techniques below are described in the chronological order in which they were
clinically developed:
1. Pre-operatively Labside, combined with guided implant surgery (CAD-CAM, Digital)
2. Per-operatively, chairside, CAD / CAM milling system (CAD-CAM, Digital)
3. Per-operatively, chairside by adding photopolymerisable increments of composite
(Flowable composite, Conventional)
All of these techniques have the advantage of insuring an immediate placement
combined with a rigid NON invasive alveolar closure. Nevertheless none of these offer the Figure 2.
SSA Gingival Fit structure showing screw retained
advantages of an industrially engineered abutment design and conceived with an ultimate «omnipost» one time one abutment final
biological and technical goal. abutment and SSA Cap Suprastructure.
In this perspective, very recently, an innovative solution entitled « SSA Gingival
Fit» (Biotech Dental) (Figure 2) abutment has been introduced into the market to meet
clinicians in need for simplification and optimal tissue integration.
The objective of this article is to discuss the technical and digital features behind this
novel immediate abutment solution and illustrate the SSA implant workflow for single
molar restoration.
CASE DESCRIPTION
A 38-YEARS OLD WOMAN, presented in our clinic for implant and prosthetic restoration
of a lower left hopeless first molar (#36). The patient’s medical history revealed no
contraindications to dental implant therapy and restorative treatment.
Treatment planning
Tooth #36 was diagnosed as untreatable due to deep root decay and lack of ferrule (Figure
3). The tooth was previously endodontically treated and slightly sensitive to percussion.
Moreover, the soft tissues are intact. No sign of acute infection was noted at the time of
clinical examination.
Figure 3.
Initial clinical situation of hopeless first lower molar and corresponding Radiograph exhibiting suitable septum
for immediate placement.
89
Based on radiographic examination (Cone Beam Computerized Tomography), the class

A septum configuration (Smith and Tarnow 2013) and apical bone volume was favorable
and compatible with:
1. a predictible and adequate insertion torque
2. perfect 3 dimensional prosthetic position.
Immediate implant placement after extraction of #36 was planned to reduce treatment
time and number of surgeries in comparison with the delayed approach. The implant
selected for this procedure was a Biotech Dental® Implant Kontact N 4.2 X10.
Surgical procedure
Atraumatic flapless tooth extraction was performed by sectioning the existing roots (Figure
4) and separating the supracrestal gingival fibers with periotomes. After extraction, the
alveolar socket was generously irrigated with sterile saline solution and cleaned with
curettes to remove granulation tissue. The osteotomy was prepared in the middle of the
septum as virtually planned in the diagnostic stage (Figure 5). A Biotech Dental® Implant
Kontact N 4.2 X10 was placed following manufacturer’s instructions (Figure 6). The
insertion torque was recorded during the placement and reached at 38N/cm. Xenograft
bone substitute (Bio-oss Collagene, 250mg Geistlisch) was packed to fill the alveolar socket
surrounding the implant (Figure 7).
Figure 4. Figure 5.
Occlusal view after tooth extraction. Intraseptal pilot Drilling.
Figure 6. Figure 7.
Immediate implant placement in the septum area Occlusal view after immediate implant placement and
(4.2x10 Kontact N, Biotech Dental). socket preservation with xenograft material.
90
Figure 8.
Occlusal view showing discrepancy between regular healing abutment and morphology of the post extraction
socket.
Figure 9.
Technical features and composition of SSA Gingival Fit abutment (Biotech Dental).
As a regular healing abutment is not fitting with the alveolar morphology (Figure 8)
and doesn’t allow for proper closure of the socket at the time of extraction, the « Sealing
Socket Concept » was applied through a novel customizable abutment system (SSA
Gingival Fit : SSA GF) specifically developed for this immediate indication. Thus, the
abutment system called SSA Gingival Fit has been utilized to simplify the obtention of
alveolar closure and optimize biological response.
The SSA Gingival Fit complex (Figure 9 and Figure 2) is a customizable healing
abutment dedicated for immediacy and made of two transmucosal components:
1. Omnipost: a narrow prosthetic abutment (Titanium) internally connected into the
implant following «one time one abutment » as it is finally delivered on the day of
surgery.
2. SSA CAP: A highly biocompatible, anatomical, customizable, scannable suprastructure
(PEEK material) connected and indexed externally onto the Omnipost that can be
selected for 3 shapes (maxillary molars, mandibular molars, Universal) to initiate the
socket sealing process.
91

Insertion of omnipost abutment onto the implant Buccal view of SSA CAP try in, connected onto the Occlusal view of SSA CAP try in, connected onto the
connection. omnipost abutment. omnipost abutment.
Figure 13.
SSA CAP customization to fit the cervical socket outline.
As the site involved here is a #36, an SSA CAP matching with a lower molar shape
component is preselected.
According to the vertical position of the implant, the appropriate gingival height is
chosen for the omnipost abutment.
The omnipost is screwed into the implant at a final torque of 20 N/cm as recommended
by the manufacturer (Figure 10). This abutment will not be removed anymore to follow the
one abutment one time protocol.
SSA CAP is manually inserted on the omnipost (Figure 11 and Figure 12), and can be
customized by adding increments of flowable composite on the extension margin of the
component which is sandblasted for improved adhesion (Figure 13).
Once customization is finalized, the SSA CAP is manually polished in the areas where
composite has been added (Figure 14a).
Finally, SSA CAP is finally tighted into the omnipost at a torque of 15 N/Cm to support
surrounding soft tissues and provide a barrier to bone substitute material without the use
of a biological membrane as described by previous authors in the situation of immediate
provisionalisation in the esthetic zone (Figure 14b) (Chu et al. 2012). Immediately after the
surgery, post-operative peri-apical radiographs (Figure 15a) were taken to verify the proper
position of the implant and the full seating of the SSA CAP onto the omnipost. At the one
week follow up, the patient reported an uneventful post-operative recovery The clinical
examination at two weeks showed a favorable soft tissue healing with minor inflammation
noted (Figure 15b).
92
a) b)
Figure 14.
a) SSA CAP customization before being screwed onto the «omnipost» abutment; b) SSA GF screwed into the
implant after final customization.
a) b)
a) Post operatory radiograph of the implant and SSA GF; b) Buccal view of the SSA GF complex at 2 weeks Buccal view of the SSA GF complex at 4 months
Follow up Follow up.
After 4 months of osseointegration, soft tissues around the SSA abutment were healthy
and the clinical buccal contour adequately maintained (Figure 16). Nevertheless, it can
be observed that some of the initial composite increments were partially lacking on the
abutment surface. The patient explained she ate accidentally on the abutment in the
late stage of osseointegration which caused its breakage. No further complications were
reported.
As described on Figure 9, the SSA GF device contains an integrated scanbody with a
scannable coding part (Flat area). Final Digital impression for implant restoration can be
performed directly on the abutment without any need of abutment removal or additional
components. Alternatively, if the digital geometry is not accessible (Adhesive resin
extension) or damaged, a digital impression can be also taken after removal of the SSA cap,
on the underlying omnipost abutment on which a scanbody is connected. This action would
not compromise the «one-time, one-abutment» protocol as the biological width remains
stable and untouched.
93
In the present case, implant impression was taken directly on the SSA GF, without
taking it out from the omnipost abutment, as it behaves also as a scanbody at this stage
(Figure 17).
The prosthetic emergence profile is replicated from a digital library containing the
specific anatomical shapes matching with the SSA GF abutment utilized and the prosthetic
emergence profile can be reproduced in consequence.
The final implant screw retained crown was designed using a design dental Software
(Exocad) and milled out of a block of Zirconia (ZirCAD Prime, Ivoclar Vivadent). The
emergence of the implant screw axis allowed for a screw retained prosthesis (Figure 18).
The crown was stained, and occlusal grooves were readjusted to improve the occlusal
anatomy. The implant crown was bonded in the lab onto a titanium base abutment
adapted for the omnipost final abutment. At the time of final crown delivery (Figure 19a),
the SSA CAP is unscrewed and removed and the final implant crown is inserted. Final
insertion torque (35N/cm) was applied and the access hole was covered with restorative
composite (Gænial A2, GC). We can notice the adequate emergence profile of the peri-
implant soft tissues precisely fitting with the transmucosal anatomy of the ceramic crown.
A post-operative periapical radiograph was taken to verify the seating and marginal
integrity after insertion (Figure 19b).
Figure 17.
Digital Files after intra-oral scanning of the SSA GF complex.
Figure 18.
Occlusal view after SSA CAP removal at the time
of implant supported rehabilitation try in.
a) b)
Figure 19.
a) Monolithic Zirconia screw retained crown at time of final delivery; b) Final Peri-apical Xray at time of final
Delivery.
94
DISCUSSION
THE PRESENT ARTICLE, DISCUSSES A CLINICAL PROTOCOL focusing on minimally
invasive surgery in molar sites, combining immediate implant placement and a chairside
manufactured customized abutment that has been previously approached in several
articles.
Immediate implant therapy in molar sites shows comparable survival rates with
implants placed in healed sites and includes highly valuable potential benefits for the
patient, including a reduction of morbidity (one surgery) (Atieh et al. 2013), reduction of
treatment time, a possible flapless procedure and reduced treatment costs.
Nevertheless, due to the anatomical morphology of the intra-alveolar socket in the molar
area, this technique remains highly challenging and relatively invasive, especially when
primary closure of the soft tissue is intended. Thus, it could be assumed that immediate
provisionalization (similar to the technique described for the esthetic area) is an interesting
alternative, behaving as a mechanical barrier, by stabilizing a freshly constituted blood clot,
and maintaining a favorable confined space for bone regeneration. Moreover, it is commonly
accepted that immediate restoration in the esthetic area provides optimal soft tissue support
for the papillae and buccal soft tissue margins (Schwartz-Arad et al. 1998; Kan et al. 2011).
However, immediate provisionalization in the molar area is poorly documented and
cannot be recommended as a safe procedure with regards to the unfavorable risk/benefit
ratio of such a procedure in a molar area.
The use of a customized healing abutment allows for the optimization of the biological
response of the transmucosal portion area without compromising the immobilization of the
fixture during healing. Recently, industrialized semi-anatomical abutments or ‘gingival
formers’ have been introduced to the market in order to guide peri-implant tissues towards
a more natural emerging shape. These standardized anatomical abutments fit well with
the indication of healed sites that exhibit a collapsed anatomy which occurred following
tooth removal; however, they lack the possibility of being fully customized. In the case
of immediate placement, a fully customized healing abutment seems to be a predictable
approach to ensure proper sealing of the socket and intimate tissue closure, which has
significant biological benefits, among which are the mechanical stability of the blood clot
in a confined space, the dimensional stabilization of the mucogingival architecture, and
guidance of a proper emergence.
The SSA concept, previously described in the literature, is utilized to ensure soft tissue
support, to avoid tissue collapse, and reduce treatment times. In a case series involving 29
patients with at least 2 years follow up, the results demonstrated uneventful postoperative
recovery and showed positive treatment outcomes with regard to implant survival and
tissue appearance (Finelle 2019).
Some recent studies have investigated the impact of customized healing abutment
on the peri-implant hard and soft tissue environment. Interestingly enough, the articles
dealing with bone volume variation showed that significantly less shrinkage was observed
after at least 3 years when a customized healing abutment is utilized in comparison with a
standard healing abutment. (Menchini-Fabris et al. 2020; Alexoupoulou 2021).
Indeed, loss of bone width appeared negligible, with values ranging between 0.2 and 0.4
mm in the customized group, whereas in the conventional group all tooth sites underwent
wide shrinkage.
In a recent prospective case series, the authors have evaluated the soft tissue contours
and the radiographic bone levels of 17 patients who received immediate implants in molar
sites and a digitally customized CAD-CAM sealing socket abutment. At the 2 years follow-
up, the overall ridge resorption calculated on the soft tissue contours at the most coronal
portion were reduced horizontally in an average of 1mm at 1,2,3 and 4mm below the
gingival margin. These results showing minimal ridge resorption are consistent with the
results observed on the bone changes articles described previously in the text (Menchini-
Fabris et al. 2020; Alexoupoulou 2021) .
95
Figure 20.
Step by step overview of SSA GF protocol:
1) Hopeless molar to be extracted; 2) Atraumatic extraction and immediate implant placement; 3) Omnipost
abutment insertion, and Socket preservation; 4) Insertion of SSA Cap before customization; 5) Customization of
SSA Cap after adhesive composite increments for socket sealing; 6) Hard and soft tissue healing around SSA GF
complex after osseointegration is completed (around 3-4 months).
Even though, increasing promising data are continuously published providing positive
information, it remains unclear which is the most adequate technique to proceed with SSA
workflow fabrication.
In this context, the present case report described the overall immediate workflow for
implant molar rehabilitation using a novel fully customizable abutment conceived for the
specific indication of immediate implant rehabilitation entitled «SSA Gingival Fit» (Biotech
Dental) (Figure 20).
Previous techniques were presented in the literature : In 2017, Finelle and Lee (Finelle
and Lee 2017) described a CAD/CAM generated SSA prepared before navigated surgery
based on virtual implant planning. This technique implies the use of a computer-guided
surgery system that allows for pre-milled prosthetic components in accordance with the
expected 3D implant position. This workflow presents few disadvantages as it is technique-
sensitive and associated with a high cost due to the outsourcing and labside fabrication.
Additionnally, possible misfit may occur in case of deviation of the implant, which would
translate to increased laboratory costs.
A more conventional technique was described in a recently published case report in
which adhesive resin composite was placed directly into the socket area.
One of the main issues of this procedure is due to the technique sensitivity and time
allocated for it. Some authors (Olabisi Arigbede et al. 2017) have also reported a cytotoxicity
effect into the deep peri-implant area, due to monomers released after the composite is
directly inserted into the wound.
The implementation of an industrialized SSA abutment (SSA GF) described in the
present investigation demonstrates a more autonomous, cost-efficient, and biologically
oriented approach, since a highly biocompatible and prefabricated anatomical abutment is
utilized in order to cover a significant majority of the emerging alveolar socket surface.
Subsequently, the SSA GF complex can be fully customized and molded with adhesive
resin onto the SSA CAP in accordance with the shape of the cervical outline of the freshly
extracted tooth.
96
In order, to respond to the biological challenge of this highly demanding transmucosal

portion, the ‘one time one abutment’ feature allows the clinician to prevent from connection/
disconnection of the abutment in the biological area. Additionnally, the transmucosal
profile is conducted with a narrow platform switched component (Finelle et al. 2015) in
highly biocompatible materials (Titanium and Peek). The composite customization is only
occupying the superficial outline of the alveolar socket which involves monomers release in
a limited extent compared to the previously described technique.
From a technical and digital stand point, the SSA GF aims to improves the
automatization of the the customization process by reducing the time of fabrication and the
quantity of intra-oral manipulation, as the abutment is already preshaped anatomically and
digitally scannable.
This techniques, and in particularly the SSA Gingival Fit abutment present significant
advantages regarding patient-centered outcomes because they reduce:
i) The overall morbidity by diminishing the length of treatment compared with
conventional approaches;
ii) the number of surgical procedure;
iii) the prosthetic manipulations and
iv) the potential cost by reducing chairside treatment time.
CONCLUSION
THE PRESENT ARTICLE REPORTS on a clinical workflow of a case report. he outcomes
observed need to be confirmed and further evaluated in well-designed controlled clinical
trials that evaluate qualitative and quantitative clinical parameters.
CLINICAL RELEVANCE
THE PROTOCOL DESCRIBED IN THIS ARTICLE provides clinical information
about a novel integrated workflow for immediate posterior implant rehabilitation.
The clinical benefit that we can foresee through this protocol are both intended to
be beneficial for the patient and the clinician.
From the patient´s point of view, we observe one single surgical appointment,
reduction of overall length of treatment and minimally post operative recovery.
From the clinician´s side, this protocols allow to reinforce blood clot
stabilization, soft tissue support leading eventually to reduced peri-implant
remodeling.
RESEARCH IMPLICATIONS
EVEN THOUGH, THE FIELD OF CUSTOMIZED HEALING ABUTMENT in
molar extraction sites is a newly explored area, it appears from the literature
analysis to raise an increased interest from the scientific community. The
early conclusions reports very interesting and promising results which need to
be confirmed and further evaluated in well-designed controlled clinical trials
evaluating qualitative and quantitative clinical parameters.
97
Akin R. (2016) A new concept in maintaining the Chen ST, Darby IB, Reynolds EC. (2007) A prospective Kan JYK, Rungcharassaeng K, Lozada JL, Zimmerman
emergence profile in immediate posterior implant clinical study of non-submerged immediate G. (2011) Facial gingival tissue stability following
placement: The anatomic harmony abutment. implants: Clinical outcomes and esthetic results. immediate placement and provisionalization of
Journal of Oral and Maxillofacial Surgery 74, 2385- Clinical Oral Implants Research 18, 552‑562. maxillary anterior single implants: A 2- to 8-year
2392. follow-up. The International Journal of Oral and
Chu SJ, Salama MA, Salama H, Garber DA, Saito
Alexopoulou M, Lambert F, Knafo B, Popelut A, Maxillofacial Implants 26, 179‑187.
H, Sarnachiaro GO, et al. (2012) The dual-zone
Vandenberghe B, Finelle G. (2021) Immediate implant therapeutic concept of managing immediate Knafo B, Finelle G. (2020) Procédés de fabrication des
in the posterior region combined with alveolar implant placement and provisional restoration piliers de cicatrisation anatomique SSA Quatre
ridge preservation and sealing socket abutment: in anterior extraction sockets. Compendium of méthodes détaillées étape par étape. Titane.
A retrospective 3D radiographic analysis. Clinical Continuing Education in Dentistry 33, 524-534. Quintessence 17(2).
Implant Dentistry and Related Research 23, 61-72.
De Rouck T, Collys K, Wyn I, Cosyn J. (2009) Instant Menchini-Fabris GB, Crespi R, Toti P, Crespi G, Rubino
Atieh MA, Alsabeeha NHM, Duncan WJ, de Silva
provisionalization of immediate single-tooth L, Covani U. (2020) A 3-year retrospective study
RK, Cullinan MP, Schwass D, Payne AGT. (2013)
implants is essential to optimize esthetic treatment of fresh socket implants: CAD/CAM customized
Immediate single implant restorations in mandibular
outcome. Clinical Oral Implants Research 20, healing abutment vs cover screws. International
molar extraction sockets: A controlled clinical trial.
566‑570. Journal of Computerized Dentistry 23, 109-117.
Clinical Oral Implants Research 24, 484‑496.
Atieh MA, Payne AGT, Duncan WJ, de Silva RK, Cullinan Finelle G, Papadimitriou DEV, Souza AB, Katebi N, Olabisi Arigbede A et al. (2017) Relative biocompatibi-
MP. (2010) Immediate Placement or immediate Gallucci GO, Araújo MG. (2015) Peri-implant soft lity of micro-hybrid and nano-hybrid light-activated
restoration/loading of single implants for molar tissue and marginal bone adaptation on implant composite resins. Journal of Dental Research Dental
tooth replacement: A systematic review and meta- with non-matching healing abutments: Micro- Clinics Dental Prospects 11, 1-6.
analysis. The International Journal of Oral and CT analysis. Clinical Oral Implants Research 26,
Retzepi M, Donos N. (2010) Guided Bone Regeneration:
Maxillofacial Implants 25, 401‑415. e42‑e46.
biological principle and therapeutic applications.
Brånemark PI. (1983) Osseointegration and its Finelle G, Lee SJ. (2017) Guided immediate implant Clinical Oral Implants Research 21, 567-576.
experimental background. Journal of Prosthetic placement with wound closure by computer-aided
Schwartz-Arad D, Chaushu G. (1998) Immediate
Dentistry 50, 399-410. design/computer-assisted manufacture sealing
implant placement: a procedure without incisions.
Bhola M, Neely AL, Kolhatkar S. (2008) Immediate socket abutment: case report. The International
Journal of Periodontology 69, 743-750.
implant placement: Clinical decisions, advantages, Journal of Oral and Maxillofacial Implants 32,
and disadvantages. Journal of Prosthodontics 17, e63‑e67. Smith RB, Tarnow DP. (2013) Classification of molar
576‑581. extraction sites for immediate dental implant
Finelle G, Sanz-Martín I, Knafo B, Figué M, Popelut
placement: technical note. The International Journal
Chen ST, Buser D. (2014) Esthetic Outcomes following A. (2019) Digitalized CAD/CAM protocol for the
of Oral and Maxillofacial Implants 28, 911-916.
immediate and early implant placement in fabrication of customized sealing socket healing
the anterior maxilla-a systematic review. The abutments in immediate implants in molar sites. Vignoletti F, Sanz M. (2014) Immediate implants at
International Journal of Oral and Maxillofacial International Journal of Computerized Dentistry 22, fresh extraction sockets: From myth to reality.
Implants 2, 186‑215. 187‑204. Periodontology 2000 66, 132‑152.
98
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AF_197X290_anuncio eSP SEPA_IN.indd 1 10/3/21 13:13
Periodoncia Clínica 2021 / 20 ‘New frontiers in immediate implantation’
02
periodonciaclínica
100
NEW FRONTIERS IN
review Biological bases of immediate implants
articles
Javier Sanz, Fabio Vignoletti, Nicola Discepoli, Javier Núñez,
Mariano Sanz
Surgical and restorative factors in immediate
implants
Antonio Liñares, Antonio Arnau, Mafalda Brinco,
Álvaro Carballo, Rafael Domínguez, Ana María Rubinos,
María Vázquez, Juan Blanco
Long-term soft tissue stability and peri-implant
aesthetics following immediate implant placement:
a critical review. Soft tissue outcomes of immediate
implants
Jan Cosyn, Lorenz Seyssens
101
Review article
BIOLOGICAL BASES
OF IMMEDIATE IMPLANTS.
JAVIER SANZ, FABIO VIGNOLETTI, NICOLA DISCEPOLI, JAVIER NÚÑEZ, MARIANO SANZ.
Javier Sanz. DDS, MSc, PhD. Complutense

University of Madrid. SUMMARY
Fabio Vignoletti. DDS, MSc, PhD. Complutense
University of Madrid. TO ACHIEVE PREDICTABLE SUCCESS in immediate implant-supported
rehabilitations, it is necessary to understand certain biological processes as well as clinical
Nicola Discepoli. DDS, MSc, PhD. Complutense
University of Madrid.
factors related to these processes. After extracting a tooth, there are dimensional changes
that mean a vertical and horizontal reduction of the alveolar socket, fundamentally
Javier Núñez. DDS, MSc, PhD. Complutense
in relation to the buccal bone plate. These changes will occur independently of the
University of Madrid.
immediate placement of an implant, in such a way that to be able to compensate for the
Mariano Sanz. MD, PhD. Professor of the physiological processes of bone resorption described above it will be necessary to place the
Complutense University of Madrid, Section of implant palatized and apicalized in relation to the alveolar socket. Thus, a gap must be
Periodontology, Department of Dental Clinical
provided by means of using implants of a reduced diameter together with their lingualized
Specialities.
placement within the socket. In cases where the residual alveolar bone plate is less than
1 mm in thickness, its bone remodelling should be mitigated by using bone substitutes
in the gap space. Because of the loss of secondary volume to the processes of alveolar
resorption, immediate implants present a buccal-plate width less than delayed implants,
which means that compensating for this loss of volume by means of connective-tissue
grafts should be considered.
INTRODUCTION
Correspondence to: FROM THE MOMENT THAT OSTEOINTEGRATION postulated dental implants as a
Javier Sanz predictable alternative in the rehabilitation of missing teeth, doubt emerged about the
javisanzes@gmail.com ideal moment to place them in relation to the extraction of the tooth.
Javier Sanz Fabio Vignoletti Nicola Discepoli Javier Núñez Mariano Sanz 102
Javier Sanz et al. Biological bases of immediate implants Review article
The third International Team for Implantology (ITI) consensus established a

classification based around the time of implant placement in relation to the extraction of
the tooth (Hämmerle et al. 2004).
• Type I (immediate placement): placement of the implant the same day as the
extraction of the tooth to be replaced in the same surgical act.
• Type II (early placement): placement of the implant after the cicatrization of the soft
tissue, but before the bone filling of the alveolar socket, about 4 to 8 weeks after the
extraction of the tooth.
• Type III (early deferred placement): placement of the implant after the initial bone
cicatrization, in which significant clinical or radiographical bone filling of the alveolar
socket should be appreciated. This takes place about 12 to 16 weeks after the tooth
extraction.
• Type IV (late or deferred placement): placement of the implant in the totally cicatrized
bone ridge. This takes place more than 16 weeks after the tooth extraction.
After the removal of the tooth, a cicatrization process begins in the alveolar tissues
(soft and hard tissues) which eventually leads to dimensional changes of the alveolar
bone. These changes have been studied in detail and quantified in preclinical models.
The experimental model in dogs is one of the most used and described in periodontal and
implant literature; the beagle dog, furthermore, because of its ease of clinical management
and its size, has been the breed most used (Struillou et al. 2010). Clinically, the majority
of the dimensional changes of the alveolar socket take place in the first three months after
the extraction and consist fundamentally in reducing its apical-coronal and buccolingual
dimensions (Schropp et al. 2003; Araújo and Lindhe 2005).
Given the importance of these dimensional changes to the clinical predictability of the
immediate implant in terms of function and aesthetics, clinical efforts have focused on
minimizing these dimensional changes at the same time as minimizing the waiting times
between the extraction of the tooth and its prosthetic replacement.
Once the predictable osteointegration of implants placed in post-extraction sockets
had been demonstrated (Anneroth et al. 1985; Karabuda et al. 1999), the possibility
of maintaining the dimensions of the alveolar bone through the immediate placement
of implants – thus avoiding the collapse following the tooth loss under the hypothesis
that the implant would act in the same way as the tooth (Paolantonio et al. 2001) – was
proposed. However, the studies by Araújo et al. (2006, 2009) on the biological process of
remodelling of the tissues after extraction and the placement of an immediate implant
showed that the changes in the alveolar ridge would take place independently of the time
in which the implants were placed (Araújo 2006a; Araújo et al. 2006b; Araújo and Lindhe
2009). From the biological point of view, among the possible justifications that have
been proposed are that the structure and function of the alveolar bone itself (fascicular
bone/bundle bone) depends on the presence of the periodontal ligament; in fact, the
periodontal ligament, the root cement, and the fascicular bone can be considered from
the embryological point of view as a single functional unit (Cardaropoli et al. 2003). More
recent preclinical research directly compared in the same animals the bone dimensional
changes after extraction and spontaneous cicatrization compared with immediate implant
placement (Vignoletti et al. 2012; Discepoli et al. 2013). In these studies, it was observed
that the immediate placement of an implant after the extraction of the tooth not only did
not prevent the bone resorption of the buccal plate but that it could also compromise the
cicatrization of the alveolar tissues, increasing the resorption of the residual buccal plate
(vertical buccal bone loss of 2.32 mm in the case of immediate implants versus 1.20 mm in
cases of spontaneous cicatrization). In addition, it was observed that the differences found
in the vertical resorption of the buccal plate increased between the second and eighth
weeks, with bone loss statistically higher in the case of immediate implant placement
(0.94 mm) compared with the spontaneous cicatrization of the alveolar socket (0.18 mm)
(Discepoli et al. 2013) (Figures 1 and 2).
103
Figure 1.
Histological sections representing the remodelling of the buccal plate after 4 hours, 1 week, 2 weeks, 4 weeks,
and 8 weeks of cicatrization. The top row shows the remodelling after the tooth extraction and the bottom row
the remodelling after the placement of an immediate implant.
Figure 2.
Histological sections which show the position of the buccal plate, compared with the position of the buccal plate
after the placement of an immediate implant.
The understanding of the biological bases that occur after the extraction of a tooth
and the immediate placement of an implant is fundamental to be able to obtain the
maximum benefit of this protocol. The aim of this review is to show the process and the
critical factors in the cicatrization of the hard and soft tissues after the placement of an
immediate implant from a biological point of view.
104
THE BIOLOGICAL PROCESS OF THE IMMEDIATE IMPLANT

Alveolar changes after tooth extraction and immediate implant placement
The biological events that take place in the tissues after the placement of an immediate
implant were originally studied with the aim of describing the process of osteointegration.
For this reason, they used implants designed specifically for this purpose, using the
creation of a trough between threads of a large size, known as a “wound chamber”
(Berglundh et al. 2003). The first tissue that forms between the implant surface and the
residual walls of the alveolar socket is the blood clot. A few hours after the placement
of the implant, the clot is replaced by a matrix of provisional connective tissue. Four
hours after the immediate placement, a wall of the residual alveolus mainly composed of
fascicular bone (bundle bone) is observed. After the first week of cicatrization, the process
of ossification starts in the interior of this connective matrix. The formation of bone occurs
both from the residual alveolar bone and at a distance in bone apposition on the implant
surface. Little by little a matrix of immature reticular bone is constructed (2 weeks),
which will later become mature cortical lamellar and medullar bone that will completely
fill the space between the threads, in this case the wound chamber. At this point, one can
observe at the same time the formation of bone and the resorption of the fascicular bone.
The bone remodelling is more evident once four weeks have passed, and after eight weeks
the remains of fascicular bone cannot be identified in the majority of samples. In this final
phase, the bone-implant contact will increase progressively until reaching levels close to
60% (4-8 weeks) (Vignoletti et al. 2009) (Figure 3).
a) b) c) d) e)
Figure 3.
Histological sections representing the formation of new bone in the wound chamber. a) Section at four hours of implant placement, where the formation of the blood
clot can be observed; b) at one week from implant placement, where the provisional osteoid matrix and the first signs of bone formation can be seen; c) after two weeks
of cicatrization, the formation of immature reticular bone in contact with the mature alveolar bone can be seen; d) after four weeks of cicatrization, the progressive
substitution of immature bone by fibrillar bone can be seen; e) after eight weeks, mature lamellar bone in contact with the surface of the implant can be seen.
The formation of the supracrestal components of the soft tissue follow the same
mechanisms as an implant placed in a cicatrized ridge: a blood clot is established between
the mucosa and the titanium of the implant. After one or two weeks one can begin to
observe vertical epithelial proliferation from the mucosal margin in an apical direction,
together with the establishment of the connective fibres oriented parallel to the axis of the
implant, against the titanium. However, in immediate implants, while the dimensions
of the connective tissue are similar to those of deferred implants, an increase of about
1 mm in the dimensions of the junctional epithelium is observed, which remains stable
throughout the morphogenetic process of the peri-implant mucosa (Berglundh et al.
2007; de Sanctis et al. 2009; Vignoletti et al. 2012). Finally, in immediate implants a total
biological space is formed of 4.93 mm at buccal level and of 4.70 mm at lingual level (1 mm
superior to the biological space described in deferred implants).
105
a) b)
Figure 4.
a) Remaining fascicular bone in implants. In this case fascicular bone can be observed only in those regions where
the remaining bone plate has sufficient width and nourishes it with vascularization; b) component of the buccal
wall formed exclusively by fascicular bone. This part of the buccal wall is present only in teeth. Its vascularization
is exclusively from the periodontal ligament which depends upon the tooth.
Simultaneously with the process of osteointegration, dimensional changes take place

in the external walls of the alveolar socket (buccal and lingual walls). After the first week,
while in the interior of the alveolar socket the matrix of connective tissue begins to be
replaced by immature bone, in the external and internal part of the corticals – both buccal
and lingual – numerous osteoclasts are observed in the process of remodelling. From the
second until the eighth week, the so-called fascicular bone or bundle bone, which depends
closely on the periodontal ligament, starts to be reabsorbed. The narrower the bone plate,
the greater percentage of fascicular bone it contains, and thus the greater bone resorption
it will suffer. Because of this, dimensional changes are generally more pronounced in the
buccal walls of the alveolar socket compared with the lingual walls (greater width and
thus more medullar bone adjacent to the fascicular bone) (Huynh-Ba et al. 2010) (Figure
4). On average, the vertical resorption observed in the buccal plate is of 0.73 ± 0.28 mm
after eight weeks of cicatrization, while in the respective lingual plate the dimensions
remain practically unchanged in terms of the vertical dimension (Araújo et al. 2006a;
Vignoletti et al. 2009; Vignoletti et al. 2012). In this respect, a prospective study evaluated
the dimensional changes that took place both in the soft tissue and in the underlying bone
tissue after tooth extraction in patients with a thin biotype, compared with patients with
a thick biotype, after eight weeks of cicatrization. They observed that patients with a thin
buccal bone plate (buccal bone plate with a thickness of 0.7 mm) experienced a vertical
bone resorption of 7.5 mm, compared to patients with a thick biotype (buccal bone plate
with a thickness of 1.4 mm), who experienced a buccal bone loss of 1.1 mm. However, at
the soft-tissue level, no differences were observed between patients with thin and thick
biotypes, indicating a physiological compensation resulting in an increase in the thickness
of the soft tissue to compensate for a greater bone loss in patients with a thin biotype.
Thus, it can be considered that in patients with a thin biotype (0.7 mm), a large amount
of the buccal bone plate will be transformed into soft tissue with the consequent alveolar
atrophy (Chappuis et al. 2015).
Various research studies have analysed the impact of the placement of an immediate
implant on the dimensional changes of the buccal plate, obtaining heterogeneous results.
Some studies observed bone resorptions of the buccal plate of 3 mm (Araújo y Lindhe
2005; Araújo et al. 2006a; Botticelli et al. 2006; Caneva et al. 2010a; Caneva et al. 2010b;
Caneva et al. 2010c), while other studies found practically no resorption of the buccal
plate (Barone et al. 2011; Favero et al. 2013). Although dimensional changes after
extraction are inevitable, independently of the placement of the implant, there are various
critical factors that can increase or mitigate the bone resorption that occurs especially in
the buccal plate.
106
FACTORS WHICH INFLUENCE BONE REMODELLING AFTER

AN IMMEDIATE IMPLANT
Implant-related factors
There are many implant-related factors that influence osteointegration, such as the
surface, the geometry, the diameter, and the position of the implant. Various studies have
investigated its influence on the dimensional changes that occur after the extraction of the
tooth and the later immediate implant.
The microtopography of the surface, so important in the process of osteointegration,
does not seem to have an influence on the maintenance of the bone dimensions. In
an experimental study that analysed the immediate placement of an implant with
modification of the surface topography using a crystalline deposition of monophosphate
particles compared to a control implant whose surface was treated by double acid etching,
no differences were found in terms of resorption of the buccal plate (Vignoletti et al. 2009).
Various experimental studies used implants of a standard diameter (4.1 mm) in
relatively small alveolar sockets, such as the premolar alveoli in beagle dogs. This
resulted in the almost total occupation of the socket by the implant, leaving a minimal
space for the formation of a blood clot between the buccal wall and the implant surface.
Thus, Araújo et al. (2006b) observed a vertical reduction of the buccal bone plate of 2.6
mm after the immediate placement of implants with a 4.1 mm diameter (Straumann
Tissue Level). However, another research group (Blanco et al. 2008) performed immediate
placement of the same implants but with a reduced diameter (Straumann Tissue Level
3.3 mm), observing half the amount of vertical reduction of the buccal plate (1.3 mm).
Another experimental study specifically analysed this question, evaluating in the same
group of animals the immediate placement of a narrow implant (3.3 mm) compared with a
wide-diameter implant (5.0 mm) (Caneva et al. 2010c). The results showed that, although
neither type of implant was able to avoid bone remodelling, the narrow-diameter implants
had significantly less vertical reduction of the buccal bone plate (1.5 mm) compared to the
wide-diameter implants (2.7 mm of vertical buccal bone loss).
It seems that the macroscopic geometry of the implants has a very limited influence
on dimensional changes in the crest. Another experimental study analysed the immediate
placement of four different implant systems (Straumann, Thommen, Astra, Biomet
3i), observing a marked buccal bone resorption in all four systems six weeks after their
placement (de Sanctis et al. 2009) (Figure 5). However, there are certain designs of the
coronal part of the implant that provide more space for the establishment of the blood
clot. An experimental study evaluated the influence on soft and hard tissues of an implant
(test) with a 4 mm reduction of the buccal portion (triangular design), compared with a
conventional cylindrical implant and the same surface (control). It was observed that,
after its immediate placement, the implant with the triangular design of the coronal part
preserved the histological width of the bone crest more than the control implant (Sanz-
Martín et al. 2017) (Figure 6). These results can be explained by the provision of extra
space in the most critical zone: between the buccal wall of the implant at coronal level and
the thinnest part of the buccal alveolar wall. It is here where it is most critical to form
the largest clot, as the thickness of the future buccal wall of the implant will depend on
the maturation of this clot; in fact, a large part of this portion of the residual wall of the
alveolar socket will be resorbed as it is composed fundamentally of fascicular bone (bundle
bone).
It seems that the implant-dependent factors that have most influence on the
maintenance of the tissue dimensions after the immediate placement of an implant are its
diameter and its position:
Together with the diameter, the position of the implant has been shown to directly
influence the dimensional changes of the ridge. Caneva et al. (2016b) evaluated the
immediate placement of implants with a narrow diameter (3.3 mm) in the centre of the
alveolar socket (control), compared to the immediate placement of similar implants but
displaced lingually and apically (test). Significantly less buccal bone resorption was
observed in the implants positioned lingually and apically (1 mm apical to the buccal
bone) compared to the implants placed in the centre of the socket.
107
a) b) c) d)
Figure 5.
Histological sections representing the position of the buccal table after three weeks of cicatrization in four types
of implant: a) Straumann 3.3; b) Thommen SPI Element 3.5; c) 3I Osseotite Miniplant Certain Straight; d) Astra 3.5
Osseospeed.
a) b)
c) d)
Figure 6.
Triangular coronal design of the implant, which allows more space for the clot in the coronal portion of the
alveolar socket after its immediate placement. Histological sections which represent the greater thickness of the
buccal plate in this design of implants compared with the control implants, both in immediate and in deferred
placement.
Thus, to reduce the bone resorption that the buccal plate experiences after the
placement of an immediate implant, it is necessary to avoid – as far as possible – coronal
contact between the implant surface and the residual buccal bone plate. This space can
be achieved using implants with a reduced diameter placed lingually and apically (1 mm
apical to the buccal bone).
108
Anatomy of the alveolar socket

Both the width of the alveolar socket and the thickness of the buccal wall are critical
factors in future dimensional changes after the placement of an immediate implant. The
group of Araújo et al. (2006b) observed in an experimental study how the same implants
(4.1 mm in diameter) placed immediately in molar alveoli presented less resorption
of the buccal plate than similar implants in premolar alveoli, whose dimensions were
significantly smaller. Later, the group of Vignoletti et al. (2009) corroborated this finding,
observing a vertical bone loss of the buccal plate of 1.1 mm when the implants were placed
immediately in the socket of the third premolar, while there was hardly any vertical bone
loss (0.3 mm) when similar implants were placed in the socket of the fourth premolar
because of its larger dimensions. These findings corroborated the need of a space between
the buccal surface of the implant and the residual buccal bone wall of the socket which
makes possible the stability of the blood clot and the later formation of the buccal plate
that recovers the coronal surface of the implant. Going against earlier science (Botticelli
et al. 2003) on the need to eliminate this buccal space or gap (the so-called “jumping
distance”), current knowledge derived from more recent research postulates that, the
larger the gap between the immediate implant surface and the residual alveolar bone
plate, the lesser the vertical reduction of the latter (Sanz et al. 2017).
Because of the greater proportion of fascicular bone when the bone plate thickness is
smaller, the thickness of the buccal bone plate is another important factor to consider.
It seems that with a thickness of less than 2 mm, the percentage of fascicular bone in
the thickness of the bone plate is greater, with minimal vascularization once the tooth
has been extracted as this fascicular bone is reabsorbed and the bone plate is left with
basically cortical bone (Spray et al. 2000; Monje et al. 2019). Thus, the vertical bone
reduction is significantly greater in those alveolar sockets whose buccal bone wall is less
that the mentioned 2 mm. These data were corroborated later at radiographical level,
where it was observed that plates of a thickness of less than 0.7 mm experienced a vertical
bone loss of 7.5 mm, compared with plates with a thickness of more than 1.4 mm where
the vertical bone loss did not exceed one millimetre (Chappuis et al. 2013). Furthermore,
at the clinical level, it was demonstrated that cases where the bone plate presents a
thickness of more than 1 mm had a residual gap 0.25 mm less at the time of re-entry, and
0.59 mm less vertical reduction of the buccal bone wall (Tomasi et al. 2010).
Surgical protocol
Various experimental investigations have shown that certain aspects of the protocol
for placing immediate implants have a direct influence on bone remodelling after an
immediate implant. Firstly, given that after the tooth extraction there is direct access to
the residual bone, it is possible to avoid raising a flap that exposes the underlying bone
at the time of placing the implant. Biologically, the act of raising a mucoperiosteal flap
implies a temporary interruption of the vascular supply between the gum-periosteum and
the bone, as well as being the trigger for an inflammatory reaction in this bone. These
inflammatory phenomena have been described in experimental research (Staffileno et al.
1966), and in some cases it has been observed that this temporary vascular interruption
caused by the raising of a flap in a tooth extraction can result in about 14% greater
dimensional reduction that when it is carried out without flap raising (Fickl et al. 2008).
The effect of raising a mucoperiosteal flap or not when placing an immediate implant
has been studied in various preclinical investigations. Blanco et al. (2008) observed a
difference of 0.55 mm more in terms of resorption of the buccal bone plate when a flap
was raised compared with not doing it when an immediate implant is placed, although
these differences were not statistically significant. On the other hand, other authors were
unable to find differences between raising or not raising a flap in terms of buccal bone
resorption after performing an extraction (Araújo and Lindhe 2011) or after the placement
of an immediate implant (Caneva et al. 2013).
109
Secondly, various studies have determined that, while dimensional changes of the
crest cannot be avoided, they can be mitigated through the use of biomaterials, such
as xenografts or autografts (Araújo and Lindhe 2011) or membranes (Caneva et al.
2010a). Nonetheless, if the gap for the blood clot is insufficient, as has been explained
above, the use of biomaterials seems to have no effect. This fact was reflected in another
investigation in which immediate implants were placed in the third premolar in an
experimental model with beagle dogs. In these sockets, of reduced dimensions, a large
vertical bone loss of the buccal bone plate was observed, independently of whether bone
substitutes were placed (1.8 mm vs. 2.1 mm) (Caneva et al. 2012). On the other hand,
when the buccal wall of an alveolar socket is sufficiently thick, there is much less buccal
resorption, similar to what occurs on the lingual plate. In these cases, the effect of the
biomaterial is also limited, as shown in a study of Labrador dogs that evaluated the use
of bone substitutes after the placement of immediate implants in sockets of molars whose
buccal plate was thick (Favero et al. 2013b). Thus, the bone resorption of the buccal
plate that occurs after the placement of an immediate implant can be reduced using
biomaterials provided that the buccal gap has adequate minimal dimensions and the
residual buccal bone table is less than 1 mm.
The biological space plays a crucial role in the maintenance of the peri-implant
bone levels. Berglundh and Lindhe (1996) observed in an experimental design that
bone resorption was consistently produced in flaps with a thickness of less than 2
mm, compared with flaps with a thickness of 2 mm or more. Furthermore, another
experimental investigation which evaluated the increase in the thickness of peri-implant
soft tissues through the use of subepithelial connective-tissue grafts after the placement of
immediate implants observed that the vertical bone resorption of the buccal plate was 0.5
mm less than in cases in which the thickness of the peri-implant connective tissue was not
increased (Caneva et al. 2013).
Historically, it was considered that the mechanical stimulus of mastication was
transmitted to the bone through the teeth and maintained the dimensions of the alveolar
bone. There was a theory that once the tooth was extracted, this stimulus disappeared,
leading to physiological resorption of the alveolar bone. This theory therefore postulated
that immediate implant placement after extraction with immediate functional loading
would provide the mechanical stimulus necessary to prevent bone resorption of the
alveolar hard tissues. Several preclinical investigations evaluated bone dimensional
stability after post-extraction implant placement with immediate loading versus
placement without immediate functional loading. These investigations observed that
immediate post-extraction loading did not alter the osseointegration process, however,
it did not prevent the physiological process of partial resorption of the residual buccal
bone table (Blanco et al. 2010; Blanco et al. 2011; Linares et al. 2011). These studies
corroborated that the biological basis of the vertical resorption of the residual alveolar
bone plate does not correspond to the absence of mechanical stimulus, but rather to the
absence of blood supply from the vascular plexus of the periodontal ligament and to the
fundamental composition of this portion of the bone plate by fascicular bone that is also
dependent on the periodontal ligament.
Immediate implants vs deferred implants

Several preclinical studies have evaluated the dimensional changes after the immediate
placement of implants compared with implants placed in cicatrized bone, both in early
and late cicatrization (Sanz-Martín et al. 2017; Vignoletti et al. 2019). As might be
expected, in both protocols a similar reduction of the buccal bone plate after implant
placement was observed. This reduction varied in relation to the cicatrization time and
to the factors previously outlined, and a vertical reduction of between 0.5 mm (Vignoletti
et al. 2019) and 1 mm (Sanz-Martín et al. 2017) after 8 and 12 weeks respectively was
observed. These reductions always occur, regardless of the placement protocol (immediate
or deferred) employed.
110
a) b) c) d)
Figure 7.
Histological sections of immediate implants (a and b) and deferred implants (c and d), compared 2 weeks after
their placement.
Figure 8.
Diagrams representing the evolution of the width of the buccal and lingual walls of immediate and deferred
implant at 2 and 8 weeks, compared with the measurements of bone plates in teeth.
In terms of the horizontal dimensional changes, big differences have been observed
between the protocol of immediate implants and that of deferred ones. The width of the
buccal bone wall in immediate implants is significantly less that the width of the buccal
wall found in implants placed with the deferred protocol (Figure 7). However, it has
been observed that the width of the buccal bone plate in immediate implants, although
less than that of deferred implants, remains unchanged between early cicatrization (2
weeks) and late cicatrization (8 weeks), while in the case of deferred implants, there
was a significant reduction in their thickness at 2 weeks compared to 8 weeks. Even so,
the thickness of the bone plate at 8 weeks in implants placed in cicatrized bone plate is
significantly greater than the thickness of the plate in immediate implants after 8 weeks
of cicatrization (Vignoletti et al. 2019) (Figure 8).
111
It should thus be taken into account that vertical dimensional changes are invariable,
independently of the time of implant placement; however, the thickness of the buccal plate
will generally be less in implants placed under the immediate protocol compared with the
protocol for placement in cicatrized plates.
Understanding of the biological process that is involved after the placement of an
immediate implant shows us that there are inevitable dimensional changes after an
extraction. However, the magnitude of those dimensional changes is influenced by factors
depending on the alveolar socket, such as the size of the gap between the implant and
the buccal wall (the bigger the space, the better), the type of implant, and the surgical
protocol used, paying particular attention to the apicalized and palatalized position of
the implant and to compensating for the loss of volume through a connective-tissue graft.
Understanding these biological bases, and using adequate tools, these factors can be
adjusted to obtain a predictable result with this rehabilitative treatment protocol.
CLINICAL RELEVANCE
TODAY THE PROTOCOLS FOR immediate implantology have become part
of everyday dental practice. There are various types of protocol and different
clinical results, for which it is necessary to understand the biological bases of the
process that occur after the extraction of a tooth and the immediate placement of
an implant, and the factors that can influence these, to thus be able to select the
protocol appropriate to the individual characteristics of each case.
THE HETEROGENEITY OF THE CLINICAL RESULTS with this type of
approach can largely be explained by in vivo preclinical studies, which provide us
with the histological dimension lacking in most clinical trials. Although many of
the factors that influence the success of immediate implants have been studied at
the histological level, there are still many other factors whose biological influence
remains unknown, and it is important to analyse them carefully in this type of
research.
112
Anneroth G, Hedstrom KG, Kjellman O, Kondell PA, Caneva M, Botticelli D, Vigano P, Morelli F, Rea M, Lang Monje A, Chappuis V, Monje F, Muñoz F, Wang HL,
Nordenram A. (1985) Endosseus titanium implants NP. (2013) Connective tissue grafts in conjunction Urban IA, Buser D. (2019) The critical peri-implant
in extraction sockets. An experimental study with implants installed immediately into extraction buccal bone wall thickness revisited: An experimental
in monkeys. International Journal of Oral and sockets. An experimental study in dogs. Clinical Oral study in the beagle dog. The International Journal of
Maxillofacial Surgery 14, 50-54. Implants Research 24, 50-56. Oral and Maxillofacial Implants 34, 1328-1336.
Araújo MG, Lindhe J. (2005) Dimensional ridge Caneva M, Salata LA, de Souza SS, Baffone G, Lang NP, Paolantonio M, Dolci M, Scarano A, d‘Archivio D, di
alterations following tooth extraction. An Botticelli D. (2010b) Influence of implant positioning Placido G, Tumini V, Piattelli A. (2001) Immediate
experimental study in the dog. Journal of Clinical in extraction sockets on osseointegration: implantation in fresh extraction sockets. A controlled
Periodontology 32, 212-218. Histomorphometric analyses in dogs. Clinical Oral clinical and histological study in man. Journal of
Araújo MG, Lindhe J. (2009) Ridge alterations following Implants Research 21, 43-49. Periodontology 72, 1560-1571.
tooth extraction with and without flap elevation: An Caneva M, Salata LA, de Souza SS, Bressan E, Botticelli Sanz M, Lindhe J, Alcaraz J, Sanz-Sánchez I, Cecchinato,
experimental study in the dog. Clinical Oral Implants D, Lang NP. (2010c) Hard tissue formation adjacent D. (2017) The effect of placing a bone replacement
Research 20, 545-549. to implants of various size and configuration graft in the gap at immediately placed implants:
Araújo MG, Lindhe J. (2011) Socket grafting with the immediately placed into extraction sockets: An A randomized clinical trial. Clinical Oral Implants
use of autologous bone: An experimental study in experimental study in dogs. Clinical Oral Implants Research 28, 902-910.
the dog. Clinical Oral Implants Research 22, 9-13. Research 21, 885-890. Sanz-Martín I, Vignoletti F, Núñez J, Permuy M, Muñoz
Cardaropoli G, Araújo M, Lindhe J. (2003) Dynamics F, Sanz-Esporrín J, Fierravanti L, Shapira L, Sanz M.
Araújo MG, Sukekava F, Wennstrom JL, Lindhe
of bone tissue formation in tooth extraction sites. (2017) Hard and soft tissue integration of immediate
J. (2006a) Tissue modeling following implant
An experimental study in dogs. Journal of Clinical and delayed implants with a modified coronal
placement in fresh extraction sockets. Clinical Oral
Periodontology 30, 809-818. macrodesign: Histological, micro-CT and volumetric
Chappuis V, Engel O, Reyes M, Shahim K, Nolte LP, soft tissue changes from a pre-clinical in vivo study.
Araújo MG, Wennstrom JL, Lindhe J. (2006b) Modeling Journal of Clinical Periodontology 44, 842-853.
Buser D. (2013) Ridge alterations post-extraction in
of the buccal and lingual bone walls of fresh
the esthetic zone: A 3D analysis with CBCT. Journal Schropp L, Wenzel A, Kostopoulos L, Karring T. (2003)
extraction sites following implant installation.
of Dental Research 92 Suppl 12, S195-S201. Bone healing and soft tissue contour changes
Clinical Oral Implants Research 17, 606-614.
Chappuis V, Engel O, Shahim K, Reyes M, Katsaros C, following single-tooth extraction: A clinical and
Barone A, Ricci M, Calvo-Guirado JL, Covani U. (2011) radiographic 12-month prospective study. The
Buser D. (2015). Soft tissue alterations in esthetic
Bone remodelling after regenerative procedures International Journal of Periodontics & Restorative
postextraction sites: A 3-dimensional analysis.
around implants placed in fresh extraction sockets: Dentistry 23, 313-323.
Journal of Dental Research 94 Suppl, S187-S193.
An experimental study in Beagle dogs. Clinical Oral
Implants Research 22, 1131-1137. De Sanctis M, Vignoletti F, Discepoli N, Zucchelli G, Sanz Spray JR, Black CG, Morris HF, Ochi S. (2000) The
M. (2009) Immediate implants at fresh extraction influence of bone thickness on facial marginal
Berglundh T, Abrahamsson I, Lang NP, Lindhe J. bone response: Stage 1 placement through stage 2
sockets: Bone healing in four different implant
(2003) De novo alveolar bone formation adjacent uncovering. Annals of Periodontology 5, 119-128.
systems. Journal of Clinical Periodontology 36, 705-
to endosseous implants. Clinical Oral Implants
711. Staffileno H, Levy S, Gargiulo A. (1966) Histologic
Research 14, 251-262.
Discepoli N, Vignoletti F, Laino L, de Sanctis M, Muñoz F, study of cellular mobilization and repair following
Berglundh T, Abrahamsson I, Welander M, Lang NP, a periosteal retention operation via split thickness
Sanz M. (2013) Early healing of the alveolar process
Lindhe J. (2007) Morphogenesis of the peri-implant mucogingival flap surgery. Journal of Periodontology
after tooth extraction: An experimental study in the
mucosa: An experimental study in dogs. Clinical Oral 37, 117-131.
beagle dog. Journal of Clinical Periodontology 40,
638-644. Struillou X, Boutigny H, Soueidan A, Layrolle P. (2010)
Berglundh T, Lindhe J. (1996) Dimension of the Favero G, Botticelli D, Favero G, García B, Mainetti T, Experimental animal models in periodontology: A
periimplant mucosa. Biological width revisited. Lang NP. (2013a) Alveolar bony crest preservation review. The Open Dentistry Journal 4, 37-47.
Journal of Clinical Periodontology 23, 971-973. at implants installed immediately after tooth Tomasi C, Sanz M, Cecchinato D, Pjetursson B, Ferrus
Blanco J, Linares A, Pérez J, Muñoz F. (2011) Ridge extraction: An experimental study in the dog. J, Lang NP, Lindhe J. (2010) Bone dimensional
alterations following flapless immediate implant Clinical Oral Implants Research 24, 7-12. variations at implants placed in fresh extraction
placement with or without immediate loading. Part Favero G, Lang NP, De Santis E, González BG, sockets: A multilevel multivariate analysis. Clinical
II: A histometric study in the Beagle dog. Journal of Schweikert MT, Botticelli D. (2013b) Ridge Oral Implants Research 21, 30-36.
Clinical Periodontology 38, 762-770. preservation at implants installed immediately after Vignoletti F, Discepoli N, Muller A, de Sanctis M,
Blanco J, Linares A, Villaverde G, Pérez J, Muñoz F. molar extraction. An experimental study in the dog. Muñoz F, Sanz M. (2012) Bone modelling at fresh
(2010) Flapless immediate implant placement Clinical Oral Implants Research 24, 255-261. extraction sockets. Immediate implant placement
with or without immediate loading: A Fickl S, Zuhr O, Wachtel H, Bolz W, Huerzeler M. (2008) versus spontaneous healing. An experimental study
histomorphometric study in beagle dog. Journal of Tissue alterations after tooth extraction with and in the beagle dog. Journal of Clinical Periodontology
Clinical Periodontology 37, 937-942. without surgical trauma: A volumetric study in the 39, 91-97.
Blanco J, Núñez V, Aracil L, Muñoz F, Ramos I. (2008) beagle dog. Journal of Clinical Periodontology 35, Vignoletti F, Johansson C, Albrektsson T, de Sanctis
Ridge alterations following immediate implant 356-363. M, San Román F, Sanz M. (2009) Early healing of
placement in the dog: Flap versus flapless surgery. Hämmerle CH, Chen ST, Wilson TG Jr. (2004) implants placed into fresh extraction sockets: An
Journal of Clinical Periodontology 35, 640-648. Consensus statements and recommended clinical experimental study in the beagle dog. De novo
Botticelli D, Berglundh T, Buser D, Lindhe J. (2003) The procedures regarding the placement of implants in bone formation. Journal of Clinical Periodontology
jumping distance revisited: An experimental study in extraction sockets. The International Journal of Oral 36, 265-277.
the dog. Clinical Oral Implants Research 14, 35-42. and Maxillofacial Implants 19 Suppl, 26-28. Vignoletti F, Sanz-Esporrín J, Sanz-Martín I, Núñez J,
Botticelli D, Persson LG, Lindhe J, Berglundh T. (2006) Huynh-Ba G, Pjetursson BE, Sanz M, Cecchinato D, Luengo F, Sanz M. (2019) Ridge alterations after
Bone tissue formation adjacent to implants placed Ferrus J, Lindhe J, Lang NP. (2010) Analysis of the implant placement in fresh extraction sockets or in
in fresh extraction sockets: An experimental study in socket bone wall dimensions in the upper maxilla healed crests: An experimental in vivo investigation.
dogs. Clinical Oral Implants Research 17, 351-358. in relation to immediate implant placement. Clinical Clinical Oral Implants Research 30, 353-363.
Caneva M, Botticelli D, Pantani F, Baffone GM, Rangel Oral Implants Research 21, 37-42.
IG Jr., Lang NP. (2012) Deproteinized bovine Karabuda C, Sandalli P, Yalcin S, Steflik DE, Parr
bone mineral in marginal defects at implants GR. (1999) Histologic and histomorphometric
installed immediately into extraction sockets: An comparison of immediately placed hydroxyapatite-
experimental study in dogs. Clinical Oral Implants coated and titanium plasma-sprayed implants: A
Research 23, 106-112. pilot study in dogs. The International Journal of Oral
and Maxillofacial Implants 14, 510-515.
Caneva M, Botticelli D, Salata LA, Scombatti Souza
SL, Carvalho Cardoso L, Lang NP. (2010a) Linares A, Mardas N, Dard M, Donos N. (2011) Effect of
Collagen membranes at immediate implants: A immediate or delayed loading following immediate
histomorphometric study in dogs. Clinical Oral placement of implants with a modified surface.
113 Implants Research 21, 891-897. Clinical Oral Implants Research 22, 38-46.
Review article
SURGICAL AND
RESTORATIVE FACTORS
IN IMMEDIATE IMPLANTS.
ANTONIO LIÑARES, ANTONIO ARNAU, MAFALDA BRINCO, ÁLVARO CARBALLO,
RAFAEL DOMÍNGUEZ, ANA MARÍA RUBINOS, MARÍA VÁZQUEZ, JUAN BLANCO.
Antonio Liñares. Associate professor of

periodontology at the University of Santiago de
Compostela, Department of complex treatments
INTRODUCTION
in periodontology and periodontal therapy
applied to implantology of the University of IN RECENT DECADES, dental implants have been the treatment of choice to replace
Santiago de Compostela, Faculty of Medicine and
Dentistry. lost teeth, with a good long-term prognosis (Jung et al. 2012; Romeo and Storelli
Antonio Arnau. Dentist. Student of the master’s 2012). Advances have been achieved in bone cicatrization, reducing the process of
degree in periodontology, USC. Department
of complex treatments in periodontology and osteointegration and, as a result, the loading protocol from the classic periods of 3-6
periodontal therapy applied to implantology of months to 6-8 weeks (Adell et al. 1981; Berglundh et al. 2003). The microtexture of the
the University of Santiago de Compostela, Faculty
of Medicine and Dentistry. implant surface has accelerated the process of osteointegration (Abrahamsson et al. 2004)
Mafalda Brinco. Dentist. Student of the master’s and, recently, its biochemistry has improved early bone cicatrization (Buser et al. 2004).
of complex treatments in periodontology and
periodontal therapy applied to implantology of
of Medicine and Dentistry.
Álvaro Carballo. Dentist. Student of the master’s
Rafael Domínguez. Dentist. Student of the
master’s degree in periodontology, USC.
Department of complex treatments in
periodontology and periodontal therapy applied
to implantology of the University of Santiago de
Compostela, Faculty of Medicine and Dentistry.
Ana María Rubinos. Dentist. Student of
the master’s degree in periodontology,
USC. Department of complex treatments in
María Vázquez. Dentist. Student of the master’s
the University of Santiago de Compostela, Faculty Antonio Liñares Antonio Arnau Mafalda Brinco Álvaro Carballo
Juan Blanco. Full professor of periodontology
at the University of Santiago de Compostela,
Department of complex treatments in
Correspondence to:
Antonio Liñares
antonio@antoniolinares.com Rafael Domínguez Ana María Rubinos María Vázquez Juan Blanco 114
Antonio Liñares et al. Surgical and restorative factors in immediate implants Review article
The ITI’s Third Consensus Conference proposed a classification system for the
placement of implants after the extraction of a tooth (Hämmerle et al. 2004). This
classification system is based on the clinical result of the process of cicatrization of the
wound:
- Type 1 placement refers to the placement of an implant on the day of tooth extraction
and within the same surgical procedure.
- Type 2 placement refers to the placement of the implant after the cicatrization of the
soft tissues but before clinically significant bone filling within the alveolar socket has
been produced.
- Type 3 placement describes the placement of the implant after a significant clinical
and/or radiological bone filling of the alveolar socket.
- Type 4 placement refers to the insertion of an implant into a completely cicatrized
zone.
Normally, between 4 and 8 weeks are needed for the soft tissues to cicatrize
sufficiently for early placement (type 2). For the early placement with partial bone
cicatrization (type 3), a cicatrization period of 12 to 16 weeks tends to be needed. For the
cicatrization for late placement (type 4), 16 or more weeks are usually necessary for the
complete cicatrization of the bone.
Ever since the first work on immediate implants, interest in this technique has
increased (Shultz 1993). The advantages are evident: fewer surgical interventions and a
reduced overall treatment time (Lazzara 1989; Parel and Triplett 1990), ideal orientation
of the implant (Werbitt and Goldberg 1992; Shultz 1993), possible preservation of the bone
in the extraction zone (Shanaman 1992; Denissen et al. 1993; Watzek et al. 1995), and the
aesthetics of soft tissues (Werbitt and Goldberg 1992). It has been demonstrated recently
that the survival rate of type-1 implants is similar to that of deferred implants (Chen
and Buser 2009; Esposito et al. 2010; Lang et al. 2012). However, preclinical studies in
humans have shown that the immediate placement of implants per se does not preserve
the anatomy of the alveolar socket, mainly in the buccal bone plate, which provokes bone
dehiscences and, later, recession of the soft tissues, affecting the aesthetic result (Araújo
et al. 2005; Araújo et al. 2006; Evans and Chen 2008; Sanz 2010; Liñares et al. 2011).
In addition, factors that can prevent bone resorption after the placement of an
immediate implant have been identified: the size of the alveolar socket (Araújo et al.
2006), the thickness of the buccal cortex (Araújo et al. 2006; Ferrus et al. 2010), the
dimensions of the buccal gap (Ferrus et al. 2010; Caneva et al. 2010), flapless procedures
(Blanco et al. 2008), the diameter of the implant (Caneva et al. 2010), the position of the
implant (Evans and Chen 2008; Caneva et al. 2010), the use of bone grafts (Araújo et al.
2011), the use of connective-tissue grafts (Caneva et al. 2013), and the use of provisional
restorations (de Rock et al. 2009). In fact, various systematic reviews have observed
greater aesthetic results with immediate implant placement and provisionalization
compared with standard protocols (Lang et al. 2012).
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SURGICAL AND RESTORATIVE FACTORS IN

THE IMMEDIATE PLACEMENT OF IMPLANTS IN
POST-EXTRACTION ALVEOLAR SOCKETS
A. SURGICAL FACTORS
1. Diameter and positioning of the implant
Preclinical studies clearly demonstrate that if the implant occupies all the dimensions of
the alveolar socket it will provoke bone loss with dehiscences, above all in the buccal plate.
Araújo et al. (2005) showed in a study with beagle dogs that immediate implants post-
extraction do not maintain the anatomy of the alveolar socket. In fact, after 3 months of
cicatrization a 2.6 mm loss of the bone plate in the vertical direction is produced. However,
in another similar study (Blanco et al. 2008), this loss was 1.3 mm. Both investigations
used the same implant and the same cicatrization time, but the diameters were different
(4.1 mm versus 3.3 mm). The diameter of the alveolar sockets ranged from 3.5 mm and
3.9 mm, for which in the research by Araújo et al. (2005) the diameter of the implant was
wider than that of the socket in the coronal part. Although one can expect a minimum
of 1 mm vertical bone loss after immediate implant placement, choosing wider implants
that contact the buccal bone wall doubles the vertical bone loss (Caneva et al. 2010).
Nonetheless, the bone loss is minimal in lingual, Thus, some authors advise placing the
implant towards the palatal/lingual bone wall and 1 mm apically to the coronal margin
of the buccal bone plate. Caneva et al. (2010) studied the influence of positioning on the
immediate placement of implants in dogs. In the control group, implants were placed in
the centre of the alveolar socket leaving the implant shoulder at the level of the buccal
crest. In the test group, implants were placed in a lingual position and 1 mm below the
buccal bone ridge. The amount of vertical buccal bone loss was 2 mm in the control group
and 1.4 mm in the test group. However, as the implant was placed 1 mm below the buccal
bone crest, a defect of only 0.4 mm was found 4 months after placement. In humans, it
has been shown that the average medio-buccal recession 18 months after the immediate
placement of implants in a more palatal position was 0.6 mm compared with 1.8 mm in
implants placed towards the buccal crest (Evans and Chen 2008).
Thus, the implant body should avoid contact with the buccal bone and they should be
placed in a more palatal position and with implants of a lesser diameter.
2. Flap vs. Flapless

Most of the experimental studies on immediate implant placement were made with
flaps (Araújo et al. 2005; Araújo et al. 2006a; Araújo et al. 2006b; Vignoletti et al. 2009).
In this context, one should emphasize the surgical trauma involved in disinserting the
periosteum, the vascular damage, and an acute inflammatory response, triggering the
resorption of the exposed bone surface
(Wood et al. 1972; Staffileno et al. 1996). This could partly explain the dimensional
changes that the alveolar socket suffers after the extraction, even if an immediate
implant is placed (Araújo et al. 2005). Blanco et al. (2008) showed that, in beagle dogs,
the resorption of buccal bone after immediate implant placement is reduced when it is
done without raising a flap. On the other hand, other studies analysed the changes of the
bone ridge after tooth extraction with or without flap raising and without the immediate
placement of the implant. After six months, alterations were observed in the bone crest
and the act of raising the flap did not influence the result of the bone cicatrization (Blanco
et al. 2008; Araújo and Lindhe 2009). In a series of human cases of a year in duration
(Raes et al. 2011), it was shown that there was a significantly smaller recession when
immediate implants were placed without flap raising.
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3. Bone graft
Araújo et al. (2011) published a study with beagle dogs in which implants were placed
after the extraction of the tooth, leaving a gap between the implant and the bone plate.
In the control group, the gap was not filled; in the test group the gap was filled with
deproteinized bovine bone with 10% porcine collagen. After six months, the control
group showed a vertical buccal bone loss of 1.33 mm (Araújo et al. 2011), similar to the
results obtained by Blanco et al. (2008). The test group did not show vertical buccal bone
loss. It thus appears that the graft material prevents vertical bone loss. Another study
with Labrador dogs found no differences between the graft and the no-graft groups.
Nonetheless, in the Labrador dog, the diameter of the alveolar socket studied is much
wider than in the beagle dog (5 mm vs. 3.5-3.9 mm). In this study, all the implants
presented an average buccal gap of 1.7 mm. Another factor is the thickness of the buccal
bone plate (thinner in the beagle than in the Labrador). Furthermore, the duration of
this study was three months compared with the six month of the first study. Thus, if the
thickness of the buccal bone plate is 1 mm or less, placing a bone graft in the buccal gap
could play an important role in the prevention of vertical bone loss (Favero et al. 2013).
Lang et al. (2012) observed that the survival rate was not affected by whether or not
the buccal gap was filled; however, there is a lack of randomized controlled trials that
evaluate success rates and, in particular, the aesthetic results (Lang et al. 2012). Only
one retrospective study compared the success rates and the responses of the peri-implant
soft and hard tissues between the placement or the non-placement of five different types
of graft. The types of graft placed in horizontal faps did not have an additional benefit in
the clinical results given that there was a thick gingival phenotype (Spinato et al. 2012).
Nonetheless, a prospective clinical study (Sanz et al. 2017) observed that, in placing a
xenograft in the gap, the horizontal resorption was significantly reduced (2.2 mm vs.
1.7 mm). Thus, with a thin gingival phenotype and a narrow buccal bone crest, it is
recommended to use a graft (biomaterial with slow resorption).
4. Connective-tissue graft
The recession of the buccal soft tissue has often been related to a buccal position of
the implant (Evans and Chen 2008) and a thin gingival phenotype (Kan et al. 2011).
Because of this, the use of connective-tissue grafts to prevent soft-tissue recession has
been proposed (Bianchi and Sanfilippo 2004). An experimental study in dogs evaluated
the effect of the placement of a connective-tissue graft in the installation of implants in
post-extraction sockets. Four months later, no statistically significant differences were
observed in vertical buccal bone loss between the test and control groups. Nonetheless, the
coronal portion of the peri-implant mucosa was significantly thicker and the margin of the
peri-implant mucosa was located significantly more coronally in the test sites compared
to the control sites. Thus, the connective-tissue graft does not seem to be so important in
terms of changes in the soft tissues, but it is important in the results of the soft tissues
(Caneva et al. 2013).
One systematic review evaluated the changes of the peri-implant tissues in immediate
single implants in the aesthetic zone. Average marginal bone loss was 0.81 ± 0.48 mm,
average interproximal peri-implant mucosa loss was 0.38 ± 0.23 mm, and the average loss
of medio-buccal peri-implant mucosa was 0.54 ± 0.39 mm (Slagter et al. 2014).
However, few studies have investigated the effect of the connective-tissue graft on
the dimension of the peri-implant soft tissue in immediate implants. One clinical trial
evaluated the remodelling of the soft tissues after the placement of immediate implants
with immediate loading with or without a soft-tissue graft using the tunnel technique.
After two years, a reduction of 10% in thickness and 18% in height was observed in the
group which did not receive grafts, while in the group that did receive grafts there was
again of 35% in thickness and a reduction of 11% in height (Migliorati et al. 2015). In
terms of vertical changes of the medio-buccal soft tissue, a recent systematic review with
meta-analysis showed a significant difference between immediate implants with and
without connective tissue grafts, of 0.41 mm in favour of the connective-tissue graft. This
result was clinically relevant given that the risk of asymmetry ≥1 mm in the vertical
level of the medio-buccal soft tissue was 12 times less when a connective-tissue graft was
applied (Seyssens et al. 2021).
117
Thus, the use of a soft-tissue graft can improve the long-term stability of the soft
tissues and the aesthetic results.
It seems that a band of keratinized mucosa of at least 2 mm can provide better
health of the peri-implant soft tissue in the long term (Wennström and Derks 2012;
Gobbato et al. 2013; Lin et al. 2013; Brito et al. 2014). However, tooth extractions and
immediate placement of implants with minimal or absent keratinised tissue continues
to take place. The use of connective-tissue grafts at the time of surgery can increase
the band of keratinized mucosa. Another option is to place a closure screw or a narrow
healing abutment and wait for spontaneous gingival regeneration (Langer 1994). The
implant is submerged, and in the second surgical phase one can achieve an increase of the
keratinized buccal mucosa by means of a lingually displaced incision.
B. RESTORATIVE FACTORS
1. Immediate loading/immediate provisionalization
Some authors have suggested that a given load can increase the amount of mineralized
bone in the bone-implant interface and in the peri-implant bone area ((Wehrbein et al.
1998; Gotfredsen et al. 2001). Immediate implants present survival rates similar to those
of deferred implants (Esposito et al. 2009). According to the ITI’s Fourth Consensus
Report, immediate loading is defined as a provisional prosthesis connected to the implant
during the first week of cicatrization, early loading between one and eight weeks of
cicatrization, and conventional loading after two months (Weber et al. 2009).
Experimental studies have shown that immediate loading per se does not affect
osteointegration compared with a protocol of delayed loading or without loading (Blanco
et al. 2010; Liñares et al. 2011). Furthermore, regarding the resorption of the buccal
bone crest, immediate loading does not influence the changes of the hard tissues after
three months of cicatrization (Blanco et al. 2010; Liñares et al. 2011; Blanco et al. 2011).
Thus, with primary stability, immediate loading can be carried out, but there will be
remodelling of the hard tissues in the buccal part.
One systematic review evaluated two protocols for immediate implants in the
aesthetic zone: the loading of a single implant in post-extraction alveolar sockets (the
bimodal approach) compared with implant loading in cicatrized sites. It observed that
immediate loading of a single implant in post-extraction sockets in the aesthetic zone
was associated with a significantly greater risk of implant failure. However, the bimodal
approach showed favourable changes in the bone margins after one year (Atieh et al.
2010). Another systematic review (Lang et al. 2012) obtained estimated annual failure
rates of conventional loading and immediate loading of 0.75% and 0.89% respectively,
without statistically significant differences. Immediately and conventionally loaded
implants showed implant survival rates of 98.2% and 98.5% respectively after two years.
However, in most of the studies there was no controlled occlusal scheme in the provisional
restorations, which could explain the lack of differences.
In the radiographic changes of the hard tissue, this systematic review showed that at
one year the loss was <1 mm and longer-term evaluations showed that the bone levels
stabilized after the first year of functioning (Lang et al. 2012).
In one prospective study, marginal bone changes at 12 months in the placement of
immediate implants with immediate restorations were studied. Half of the bone loss
measured in the first year was produced in the first three months (de Rock et al. 2009).
118
Furthermore, one systematic review highlighted that the delay in the

provisionalization of immediate implants increased by 20 times the probability of
suffering changes >0.5 mm at the peri-implant marginal bone level. Thus, it seems that
the use of an immediate provisional restoration can obtain better peri-implant bone levels.
This can be critical when evaluating peri-implant soft tissues (Slagter et al. 2014). The
recession of the peri-implant buccal mucosa was 0.43 ± 0.38 mm in comparison with the
presurgical level. The soft tissues were stabilized after six months, as by the end of the
first year there had been a retraction of 0.49 ± 0.31 mm in the mesial papilla, 0.38 ± 0.33
mm in the distal, and 0.51 ± 0.38 in the margin of the buccal mucosa compared with the
initial level. If the results obtained are analysed comparing the immediate placement of
the implant and the provisional restoration with a deferred restoration, they show that
at three months the average contraction of the papilla was approximately double in the
deferred-restoration group than in the immediate-restoration group (de Rock et al. 2009).
However, over the following nine months, the deferred restorations showed a tendency
to fill the proximal spaces and the differences between the two groups reduced. If the
changes in the medio-buccal mucosa are analysed, the apical displacement was two or
three times greater in the deferred-restoration group than in the immediate-provisional
group after one year of follow-up. It was concluded that this difference would favour
immediate restoration in the immediate placement of the implant (de Rock et al. 2009).
2. Platform switching
Although the use of a technique of platform switching – in which an implant of a greater
diameter is restored with an abutment of a narrower diameter to minimize the changes
in the hard tissues – has been studied, this concept seems to be controversial and requires
more research (Canullo et al. 2009). A randomized clinical trial studied radiographic
bone changes after the placement of independent implants with immediate restorations
(Crespi et al. 2009). After 24 months, the differences between the group with the switched
platform and the group with the external hexagon were not significant. A prospective
study evaluated the survival rates at 12 months of implants with a platform-switched
design placed in the anterior and premolar zones of the maxilla and restored immediately
with individual crowns. The average bone loss at one year measured in the mesial zones
was 0.08 mm (SD 0.53 mm) and 0.09 mm (SD 0.65 mm) in the distal zones (Calvo-Guirado
et al. 2009). The small bone changes coincided with those observed by Canullo et al:
(2009), which showed that, after some two years of loading, the platform-switched group
experienced a bone loss of 0.25 mm at mesial level and of 0.36 mm at distal level; the bone
loss was more significant in the group which did not have platform switching, reaching
1.13 mm and 1.25 mm in the mesial and distal surfaces respectively.
3. Connection-disconnection
It has been reported that the multiple disconnections and reconnections of the abutments
after the placement of implants can compromise the peri-implant mucosal seal and
provoke an increase in marginal bone loss (Abrahamsson et al. 1997; Rodríguez et al.
2013). The additional marginal bone loss after the manipulation of the abutments may be
the result of tissue reactions initiated to establish an adequate “supracrestal connective-
tissue attachment”. However, a randomized clinical controlled trial showed that the
average marginal bone loss at six months was 0.13 mm for implants placed in cicatrized
sites and connected on the day of surgery to a definitive abutment; the average bone loss
in the group in which the abutment was connected and disconnected was 0.28 mm. These
results were not significant and there were no significant differences between the groups
in terms of the changes in the peri-implant mucosa.
119
It therefore seems that, in the short term, in cicatrized sites there is no difference
between placing a definitive abutment at the time of implant surgery and using the
standard protocol of implant-level impressions and the connection/disconnection of the
abutment after the process of osteointegration (Koutouzis et al. 2013). In terms of post-
extraction sockets and immediate implants, Canullo et al. (2010) published the results of
a trial of three years duration. The aim was to evaluate the influence of the restoration on
the marginal bone loss, using immediate definitive abutments or provisional abutments
replaced later with definitive ones. In the provisional-abutment group, the peri-implant
bone resorption was 0.36 mm at three months, 0.43 mm at 18 months, and 0.55 mm at
three years. In the definitive-abutment group, the peri-implant bone resorption was 0.35
mm, 0.33 mm, and 0.34 mm at the same time points. The lesser amount of bone loss was
significant in the definitive-pillar group at 12 months (0.1 mm) and at three years (0.2
mm) (Canullo et al. 2010). This essay suggested that the use of definitive abutments after
immediate implant placement could be a potential factor to minimize peri-implant crestal
bone resorption, but more clinical trials should be carried out to better investigate this
hypothesis.
4. Size of the prosthetic abutment

In the context of provisional restoration and definitive abutments, studies have not
addressed the length of the abutments. The concept of biological width plays an important
role in the changes of the tissues in implants. Studies carried out at the end of the 1990s
clearly showed that, when the connection of the prosthesis is closer to the heads of the
implant, there is greater bone loss (Hermann et al. 1997; Hermann et al. 2001a; Hermann
et al. 2001b; Hermann et al. 2001c). These studies were performed in cicatrized ridges.
But the coronal part of the extraction socket tends not to be flat, with more coronal level
of the interproximal bone than on the buccal side. Thus, if the recommendation to place
immediate implants 1 mm below the buccal bone plate is taken then longer abutments
must be used. For example, an abutment of 1 mm can be almost at the buccal bone level,
but probably subcrestal at the proximal sites. It is to be hoped that the remodelling of the
hard tissues induces a bone loss to establish an adequate biological width, as the position
of the connective tissue is always apical to the abutment/restoration connection (Hermann
et al. 1997; Hermann et al. 2001a; Hermann et al. 2001b; Hermann et al. 2001c). In
immediate post-extraction implants, longer abutments are recommended to avoid a
greater bone loss. However, although this is biologically plausible, it has not been proven
either experimentally or clinically.
CONCLUSION AND CLINICAL RECOMMENDATIONS

A DETAILED DIAGNOSIS SHOULD BE MADE when choosing an immediate
approach. If one opts for the immediate placement of the implant, after the atraumatic
extraction, a careful curettage of the alveolar socket with curettes and a saline solution
or chlorhexidine is recommended. The walls of the socket should be inspected to check for
the absence of bone defects. The dimensions of the (buccal) soft tissue can be measured
to place the implant according to the soft-tissue margin. The implant should be placed
towards the palatal wall and 1 mm subcrestal to the buccal bone plate. However,
sometimes the implant cannot be placed in this position, so it is important that the
placement be prosthetically guided. The buccal gap is filled with a bone graft of slow
resorption. But in cases with a thick buccal plate (>1.5 mm), thick phenotype, and a gap
<1.5 mm, the graft does not need to be placed as its probable benefit will be minimal. One
can perform a connective-tissue graft in the buccal zone (thin gingival phenotype and high
aesthetic requirements). If primary stability is achieved, a provisional restoration can be
placed. Occlusal contacts should be avoided, above all in single restorations. Provisional
abutments and restorations should respect the proximal soft and hard tissues. It is thus
advisable to use the concept of platform-switching with narrow pillars and prosthesis of
the “one abutment, one time” concept.
120
CLINICAL CASE
A 30-YEAR-OLD PATIENT with a horizontal facture at the level of the middle third of
the root in the upper right lateral incisor and a gingival tear at the level of the distal
papilla through traumatism (Figures 1 and 2).
The atraumatic extraction was performed followed by the placement of an immediate
implant without flap raising and an envelope connective-tissue graft was placed in the
zone of distal mucosal dehiscence. An immediate provisionalization was made with a
provisional abutment and the clinical crown of the tooth itself (Figures 3, 4, and 5).
At three months of cicatrization, a defect in the distal papilla was observed. The
emergence profile of the immediate load was modified for the modelling of the soft tissues
(Figures 6 and 7), and at six months a tunnelled connective-tissue graft was made under
the distal papilla and in the buccal zone (Figures 8, 9, 10, and 11).
Four months after the graft the soft-tissue defect continued, so it was corrected with
the definitive crown and a composite restoration on the mesial face of the canine tooth
(Figures 12 and 13).
At the two-year follow-up, the clinical and radiographical examination showed
stability of the peri-implant soft and hard tissues and an excellent aesthetic result
(Figures 14 and 15).
Figure 16 shows the maturation of the soft tissues over the follow-up period.
Figures 1 and 2.
Pre-operative clinical and radiographical images.
Figures 3, 4, and 5.
Position of the immediate implant, connective-tissue graft, and immediate provisional.
121
Figures 6 and 7.
Modelling of the soft tissues.
Figures 8, 9, 10 and 11.

Connective-tissue graft, connection of the definitive abutment, and provisional crown.
122
Figures 12 and 13.

Definitive crown.
Figures 14 and 15.

Clinical and radiographic control at the two-year follow-up.
a) b)
c) d)
Figure 16.
Maturing of the soft tissues: a) two months after implant placement, two months after the installation of the
immediate implant with immediate loading; b) two months after the modelling of the soft tissues; c) four
months after the connective tissue graft, definitive abutment connection, and placement of the provisional
crown; d) at the two-year follow-up.
123
CLINICAL RELEVANCE
Clinical justification of the study
There are studies in humans and pre-clinical models that show that after the
placement of immediate implants there are bone dehiscences and later recession
of the soft tissues, with a great impact on aesthetic results.
In contrast, various systematic reviews have shown better aesthetic
conditions with immediate implant placement and provisionalization compared
with standard protocols.
Main findings
For the choice of an approach of immediate post-extraction implants with
predictable results, it is necessary to perform a detailed diagnosis, check for the
absence of bone defects, place the implant towards the palatal wall, and 1 mm
subcrestal to the buccal bone plate. Use a surgical approach without flap raising
wherever possible to avoid a greater bone resorption.
When we have a thin gingival phenotype and a narrow buccal bone crest,
the use of a connective-tissue graft at the time of surgery to increase the band
of keratinized mucosa can be recommended. Another option would be to place a
closure screw or a narrow healing abutment and wait for spontaneous gingival
regeneration. The implant will be submerged, and in the second surgical phase
an increase in buccal keratinized mucosa can be achieved through a lingually
displaced incision.
To respect the soft and hard tissues, the use of the concept of platform
switching with narrow abutments is recommended along with the concept of “one
abutment, one time.”
THE USE OF THESE PROCEDURES allows us to know that we can have
predictable and successful results with the technique of immediate post-
extraction implant placement.
124
Abrahamsson I, Berglundh T, Linder E, Lang NP, Buser D, Martin W, Belser UC. (2004) Optimizing Evans CD, Chen ST. (2008) Esthetic outcomes of
Lindhe J. (2004) Early bone formation adjacent to esthetics for implant restorations in the anterior immediate implant placements. Clinical Oral
rough and turned endosseous implant surfaces. An maxilla: Anatomic and surgical considerations. Implants Research 19, 73-80.
experimental study in the dog. Clinical Oral Implants The International Journal of Oral and Maxillofacial Favero G, Lang NP, De Santis E, González BG,
Research 15, 381-392. Implants 19 Suppl, 43-61. Schweikert MT, Botticelli D. (2013) Ridge
Abrahamsson I, Berglundh T, Lindhe J. (1997) Calvo-Guirado JL, Ortiz-Ruiz AJ, López-Marí L, Delgado- preservation at implants installed immediately after
The mucosal barrier following abutment dis/ Ruiz R, Maté-Sánchez J, Bravo González LA. (2009) molar extraction. An experimental study in the dog.
reconnection. An experimental study in dogs. Immediate maxillary restoration of single-tooth Clinical Oral Implants Research 24, 255-261.
Journal of Clinical Periodontology 24, 568-572. implants using platform switching for crestal bone Ferrus J, Cecchinato D, Pjetursson EB, Lang NP, Sanz M,
Adell R, Lekholm U, Rockler B, Brånemark PI. (1981) preservation: A 12-month study. The International Lindhe J. (2010) Factors influencing ridge alterations
A 15-year study of osseointegrated implants in Journal of Oral and Maxillofacial Implants 24, 275- following immediate implant placement into
the treatment of the edentulous jaw. International 281. extraction sockets. Clinical Oral Implants Research
Journal of Oral Surgery 10, 387-416. Caneva M, Botticelli D, Viganò P, Morelli F, Rea M, Lang 21, 22-29.
Araújo MG, Linder E, Lindhe J. (2011) Bio-Oss collagen NP. (2013) Connective tissue grafts in conjunction Gobbato L, Ávila-Ortiz G, Sohrabi K, Wang CW,
in the buccal gap at immediate implants: A 6-month with implants installed immediately into extraction Karimbux N. (2013) The effect of keratinized mucosa
study in the dog. Clinical Oral Implants Research 22, sockets. An experimental study in dogs. Clinical Oral width on peri-implant health: A systematic review.
1-8. Implants Research 24, 50-56. The International Journal of Oral and Maxillofacial
Araújo MG, Lindhe J. (2005) Dimensional ridge Caneva M, Salata LA, de Souza SS, Baffone G, Lang NP, Implants 28, 1536-1545.
alterations following tooth extraction. An Botticelli D. (2010) Influence of implant positioning Gotfredsen K, Berglundh T, Lindhe J. (2001) Bone
experimental study in the dog. Journal of Clinical in extraction sockets on osseointegration: reactions adjacent to titanium implants subjected
Periodontology 32, 212-218. Histomorphometric analyses in dogs. Clinical Oral to static load. A study in the dog (I). Clinical Oral
Implants Research 21, 43-49. Implants Research 12, 1-8.
Araújo MG, Lindhe J. (2009) Ridge alterations following
Caneva M, Salata LA, de Souza SS, Bressan E, Botticelli Hämmerle CH, Chen ST, Wilson TG Jr. (2004)
tooth extraction with and without flap elevation: An
D, Lang NP. (2010) Hard tissue formation adjacent Consensus statements and recommended clinical
experimental study in the dog. Clinical Oral Implants
to implants of various size and configuration procedures regarding the placement of implants in
Research 20, 545-549.
immediately placed into extraction sockets: An extraction sockets. The International Journal of Oral
Araújo MG, Sukekava F, Wennström JL, Lindhe J. (2005) experimental study in dogs. Clinical Oral Implants and Maxillofacial Implants 19 Suppl, 26-28.
Ridge alterations following implant placement in Research 21, 885-890.
fresh extraction sockets: An experimental study in Hermann JS, Buser D, Schenk RK, Schoolfield JD,
Canullo L, Bignozzi I, Cocchetto R, Cristalli MP, Iannello Cochran DL. (2001a) Biologic Width around one-
the dog. Journal of Clinical Periodontology 32, 645-
G. (2010) Immediate positioning of a definitive and two-piece titanium implants. Clinical Oral
652.
abutment versus repeated abutment replacements Implants Research 12, 559-571.
Araújo MG, Sukekava F, Wennström JL, Lindhe in post-extractive implants: 3-year follow-up of
J. (2006a) Tissue modeling following implant a randomised multicentre clinical trial. European Hermann JS, Cochran DL, Nummikoski PV, Buser D.
placement in fresh extraction sockets. Clinical Oral Journal of Oral Implantology 3, 285-296. (1997) Crestal bone changes around titanium
Implants Research 17, 615-624. implants. A radiographic evaluation of unloaded
Canullo L, Iurlaro G, Iannello G. (2009) Double-blind nonsubmerged and submerged implants in the
Araújo MG, Wennström JL, Lindhe J. (2006b) Modeling randomized controlled trial study on post-extraction canine mandible. Journal of periodontology 68,
of the buccal and lingual bone walls of fresh immediately restored implants using the switching 1117-1130.
extraction sites following implant installation. platform concept: Soft tissue response. Preliminary
Clinical Oral Implants Research 17, 606-614. report. Clinical Oral Implants Research 20, 414-420. Hermann JS, Schoolfield JD, Nummikoski PV, Buser
D, Schenk RK, Cochran DL. (2001b) Crestal bone
Atieh MA, Payne AG. Duncan WJ, De Silva RK, Cullinan Chen ST, Buser D. (2009) Clinical and esthetic outcomes changes around titanium implants: A methodologic
MP. (2010) Immediate placement or immediate of implants placed in postextraction sites. The study comparing linear radiographic with histometric
restoration/loading of single implants for molar International Journal of Oral and Maxillofacial measurements. The International Journal of Oral
tooth replacement: A systematic review and meta- Implants 24 Suppl, 186-217. and Maxillofacial Implants 16, 475-485.
analysis. The International Journal of Oral and
Crespi R, Capparè P, Gherlone E. (2009) Radiographic Hermann JS, Schoolfield JD, Schenk RK, Buser D,
Maxillofacial Implants 25, 401-415.
evaluation of marginal bone levels around platform- Cochran DL. (2001c) Influence of the size of the
Berglundh T, Abrahamsson I, Lang NP, Lindhe J. switched and non-platform-switched implants used microgap on crestal bone changes around titanium
(2003) De novo alveolar bone formation adjacent in an immediate loading protocol. The International implants. A histometric evaluation of unloaded non-
to endosseous implants. Clinical Oral Implants Journal of Oral and Maxillofacial Implants 24, 920-926. submerged implants in the canine mandible. Journal
Research 14, 251-262. of periodontology 72, 1372-1383.
De Rouck T, Collys K, Cosyn J. (2008) Immediate single-
Bianchi AE, Sanfilippo F. (2004) Single-tooth tooth implants in the anterior maxilla: A 1-year Jung RE, Zembic A, Pjetursson BE, Zwahlen M, Thoma
replacement by immediate implant and connective case cohort study on hard and soft tissue response. DS. (2012) Systematic review of the survival rate and
tissue graft: A 1-9-year clinical evaluation. Clinical Journal of Clinical Periodontology 35, 649-657. the incidence of biological, technical, and aesthetic
Oral Implants Research 15, 269-277. De Rouck T, Collys K, Wyn I, Cosyn J. (2009) Instant complications of single crowns on implants reported
Blanco J, Liñares A, Pérez J, Muñoz F. (2011) Ridge provisionalization of immediate single-tooth in longitudinal studies with a mean follow-up of 5
alterations following flapless immediate implant implants is essential to optimize esthetic treatment years. Clinical Oral Implants Research 23 Suppl 6,
placement with or without immediate loading. Part outcome. Clinical Oral Implants Research 20, 566- 2-21.
II: A histometric study in the Beagle dog. Journal of 570. Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman
Clinical Periodontology 38, 762-770. Denissen HW, Kalk W, Veldhuis HA, van Waas MA. G. (2011) Facial gingival tissue stability following
Blanco J, Liñares A, Villaverde G, Pérez J, Muñoz F. (1993) Anatomic consideration for preventive immediate placement and provisionalization of
(2010) Flapless immediate implant placement implantation. The International Journal of Oral and maxillary anterior single implants: A 2- to 8-year
with or without immediate loading: A Maxillofacial Implants 8, 191-196. follow-up. The International Journal of Oral and
histomorphometric study in beagle dog. Journal of Esposito M, Grusovin MG, Achille H, Coulthard P, Maxillofacial Implants 26, 179-187.
Clinical Periodontology 37, 937-942. Worthington HV. (2009) Interventions for replacing Kan JY. Rungcharassaeng K, Umezu K, Kois JC. (2003)
Blanco J, Núñez V, Aracil L, Muñoz F, Ramos I. (2008) missing teeth: Different times for loading dental Dimensions of peri-implant mucosa: an evaluation
Ridge alterations following immediate implant implants. The Cochrane database of systematic of maxillary anterior single implants in humans.
placement in the dog: Flap versus flapless surgery. reviews , CD003878. Journal of Periodontology 74, 557-562.
Journal of Clinical Periodontology 35, 640-648. Esposito M, Grusovin MG, Polyzos IP, Felice P, Koutouzis T, Koutouzis G, Gadalla H, Neiva R. (2013)
Brito C, Tenenbaum HC, Wong BK, Schmitt C, Worthington HV. (2010) Timing of implant The effect of healing abutment reconnection and
Nogueira-Filho G. (2014) Is keratinized mucosa placement after tooth extraction: Immediate, disconnection on soft and hard peri-implant tissues:
indispensable to maintain peri-implant health? immediate-delayed or delayed implants? A A short-term randomized controlled clinical trial.
A systematic review of the literature. Journal of Cochrane systematic review. European Journal of The International Journal of Oral and Maxillofacial
Biomedical Materials Research 102, 643-650. Oral Implantology 3, 189-205. Implants 28, 807-814.
125
Lai HC, Zhuang LF, Zhang ZY, Wieland M, Liu X. (2009) Rodríguez X, Vela X, Méndez V, Segalà M, Calvo- Spinato S, Agnini A, Chiesi M, Agnini AM, Wang HL.
Bone apposition around two different sandblasted, Guirado JL, Tarnow DP. (2013) The effect of (2012) Comparison between graft and no-graft in
large-grit and acid-etched implant surfaces at abutment dis/reconnections on peri-implant bone an immediate placed and immediate nonfunctional
sites with coronal circumferential defects: An resorption: A radiologic study of platform-switched loaded implant. Implant Dentistry 21, 97-103.
experimental study in dogs. Clinical Oral Implants and non-platform-switched implants placed in Staffileno H, Levy S, Gargiulo A. (1966) Histologic
Research 20, 247-253. animals. Clinical Oral Implants Research 24, 305- study of cellular mobilization and repair following
311. a periosteal retention operation via split thickness
Lang NP, Pun L, Lau KY, Li KY, Wong MC. (2012) A
systematic review on survival and success rates of Romeo E, Storelli S. (2012) Systematic review of the mucogingival flap surgery. Journal of Periodontology
implants placed immediately into fresh extraction survival rate and the biological, technical, and 37, 117-131.
sockets after at least 1 year. Clinical Oral Implants aesthetic complications of fixed dental prostheses Vignoletti F, de Sanctis M, Berglundh T, Abrahamsson
Research 23 Suppl 5, 39-66. with cantilevers on implants reported in longitudinal I, Sanz M. (2009) Early healing of implants placed
studies with a mean of 5 years follow-up. Clinical into fresh extraction sockets: An experimental study
Langer B. (1994) Spontaneous in situ gingival Oral Implants Research 23 Suppl 6, 39-49. in the beagle dog. III: Soft tissue findings. Journal of
augmentation. The International Journal of
Sanz M, Cecchinato D, Ferrus J, Pjetursson EB, Lang Clinical Periodontology 36, 1059-1066.
Periodontics & Restorative Dentistry 14, 524-535.
NP, Lindhe J. (2010) A prospective, randomized- Watzek G, Haider R, Mensdorff-Pouilly N, Haas R.
Lazzara RJ. (1989) Use of osseointegrated implants controlled clinical trial to evaluate bone preservation (1995) Immediate and delayed implantation for
for replacement of single teeth. Compendium using implants with different geometry placed complete restoration of the jaw following extraction
(Newtown, Pa.) 10, 550-554. into extraction sockets in the maxilla. Clinical Oral of all residual teeth: A retrospective study comparing
Lin GH, Chan HL, Wang HL. (2013) The significance of Implants Research 21, 13-21. different types of serial immediate implantation.
keratinized mucosa on implant health: A systematic The International Journal of Oral and Maxillofacial
Schultz AJ. (1993) Guided tissue regeneration (GTR) of
review. Journal of Periodontology 84, 1755-1767. Implants 10, 561-567.
nonsubmerged implants in immediate extraction
sites. Practical Periodontics and Aesthetic Dentistry Weber HP, Morton D, Gallucci GO, Roccuzzo M,
Liñares A, Mardas N, Dard M, Donos N. (2011) Effect of
5, 59-66. Cordaro L, Grutter L. (2009) Consensus statements
immediate or delayed loading following immediate
and recommended clinical procedures regarding
placement of implants with a modified surface. Schwarz F, Herten M, Sager M, Bieling K, Sculean A, loading protocols. The International Journal of Oral
Clinical Oral Implants Research 22, 38-46. Becker J. (2007) Comparison of naturally occurring and Maxillofacial Implants 24 Suppl, 180-183.
Migliorati M, Amorfini L, Signori A, Biavati AS, and ligature-induced peri-implantitis bone defects in
Wehrbein H, Merz BR, Hämmerle CH, Lang NP. (1998)
Benedicenti S. (2015) Clinical and aesthetic outcome humans and dogs. Clinical Oral Implants Research
Bone-to-implant contact of orthodontic implants
with post-extractive implants with or without soft 18, 161-170.
in humans subjected to horizontal loading. Clinical
tissue augmentation: A 2-year randomized clinical Seyssens L, De Lat L, Cosyn J. (2021) Immediate implant Oral Implants Research 9, 348-353.
trial. Clinical Implant Dentistry and Related Research placement with or without connective tissue graft: Wennström JL, Derks J. (2012) Is there a need for
17, 983-995. A systematic review and meta-analysis. Journal of keratinized mucosa around implants to maintain
Parel SM, Triplett RG. (1990) Immediate fixture Clinical Periodontology 48, 284-301. health and tissue stability? Clinical Oral Implants
placement: A treatment planning alternative. The Shanaman RH. (1992) The use of guided tissue Research 23 Suppl 6, 136-146.
International Journal of Oral and Maxillofacial regeneration to facilitate ideal prosthetic placement Werbitt MJ, Goldberg PV. (1992) The immediate
Implants 5, 337-345. of implants. The International Journal of Periodontics implant: bone preservation and bone regeneration.
Raes F, Cosyn J, Crommelinck E, Coessens P, De Bruyn H. & Restorative Dentistry 12, 256-265. The International Journal of Periodontics &
(2011) Immediate and conventional single implant Slagter KW, den Hartog L, Bakker NA, Vissink A, Restorative Dentistry 12, 206-217.
treatment in the anterior maxilla: 1-year results of Meijer HJ, Raghoebar GM. (2014) Immediate Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD.
a case series on hard and soft tissue response and placement of dental implants in the esthetic zone: (1972) Alveolar crest reduction following full and
aesthetics. Journal of Clinical Periodontology 38, A systematic review and pooled analysis. Journal of partial thickness flaps. Journal of Periodontology 43,
385-394. Periodontology 85, e241-e250. 141-144.
126
ADVERTISING
127
Review article
LONG-TERM SOFT TISSUE STABILITY

AND PERI-IMPLANT AESTHETICS
FOLLOWING IMMEDIATE IMPLANT
PLACEMENT: A CRITICAL
SOFT TISSUE OUTCOMES OF IMMEDIATE IMPLANTS.
REVIEW.
JAN COSYN, LORENZ SEYSSENS.
Jan Cosyn. DDS MSC PhD, Professor and

Chairman. Ghent University, Faculty of
Medicine and Health Sciences, Oral Health
SUMMARY
Sciences, Department of Periodontology and Objectives
Oral Implantology, Ghent, Belgium. Vrije To assess long-term papillary changes, midfacial soft tissue changes and peri-implant
Universiteit Brussel (VUB), Faculty of Medicine
aesthetics following immediate implant placement (IIP).
and Pharmacy, Oral Health Research Group
(ORHE), Brussels, Belgium.
Materials and methods
Lorenz Seyssens. DDS, PhD student. Ghent An electronic search was performed in Pubmed up to January 2021 to identify randomized
University, Faculty of Medicine and Health controlled trials (RCTs), cohort studies and case series on IIP with data on soft tissue
Sciences, Oral Health Sciences, Department of
changes and/or peri-implant aesthetics after at least 5 years of follow-up.
Periodontology and Oral Implantology, Ghent,
Belgium.
Results
Eleven studies could be identified (2 RCTs, 2 cohort studies, 7 case series) reporting on
637 implants installed in 437 patients. Minimal papillary changes were found following
IIP. Apart from one study, all reported acceptable midfacial recession below 0.6 mm.
However, frequency distributions from two studies indicated ≥ 1 mm midfacial recession
in 21% and 33% of the cases. Pink Esthetic Score (PES) was well above 10 in all studies,
indicative of an overall acceptable aesthetic outcome in the long term. “Alveolar process”
was most critical in all studies using the original PES and deteriorated over time in two
studies.
Conclusion
Limited soft tissue changes and acceptable aesthetics have been described for IIP in the
long term, although loss of buccal convexity seems common. These findings pertain to
Correspondence to: patients who were treated by experienced clinicians. Stringent case selection, meticulous
Jan Cosyn implant placement, hard and soft tissue grafting are key elements for stable soft tissues
Jan.Cosyn@UGent.be and favorable aesthetics in the long term.
Jan Cosyn Lorenz Seyssens 128

Jan Cosyn, Long-term soft tissue stability and peri-implant aesthetics following immediate implant placement: Review article
Lorenz Seyssens a critical review. Soft tissue outcomes of immediate implants
INTRODUCTION
IMMEDIATE IMPLANT PLACEMENT (IIP) has always been very attractive to patients
and clinicians since it reduces the number of surgical interventions and the overall
treatment time. However,
clinicians are faced with a number of challenges when placing an implant into
an extraction socket. Primary implant stability is sometimes difficult to achieve and
may explain a 4% higher early failure rate for IIP when compared to delayed implant
placement (Cosyn et al. 2019). In a recent consensus meeting, it was concluded that IIP
should not be performed in severely damaged alveolar sockets and at extraction sites in
which achievement of primary stability requires placement in a prosthetically incorrect
position or selection of a too wide implant (Tonetti et al. 2019). This is related to the fact
that IIP is not able to avoid the buccal hard and soft tissue remodeling following tooth
extraction (Botticelli et al. 2004; Araujo et al. 2005; Covani et al. 2007; Vignoletti et al.
2009). Hence, clinicians need to anticipate by stringent case selection and by meticulous
implant positioning at the palatal aspect to avoid buccal tissue alterations that may
compromise aesthetics.
Even so, midfacial recession seems to be a concern following IIP (Cosyn et al. 2012a;
Chen and Buser 2014; Lin et al. 2014). In a systematic review by Chen and Buser (2014),
26% of immediately installed implants displayed advanced midfacial recession (≥ 1 mm).
Also, satisfactory results observed during the first year of function may still be followed by
progressive recession over time (Kan et al. 2011; Cosyn et al. 2016; Seyssens et al. 2020).
Hence, the objective of this critical review was to assess the long-term outcome of IIP
in terms of soft tissue stability and peri-implant aesthetics.
MATERIALS AND METHODS

Search strategy
An electronic search was performed in Pubmed up to January 2021 using a combination of
the following MeSH terms and keywords:
Patient ((extraction, tooth [MeSH Terms] OR immediate placement OR

immediately placed OR immediate installation OR immediately
installed OR immediate insertion OR immediately inserted OR
immediate implants OR fresh extraction socket) AND (dental
implant [MeSH Terms] OR dental implantation [MeSH Terms] OR
dental implant OR dental implantation OR oral implant OR tooth
implant OR tooth implantation))
Outcome (((((gingival recession [MeSH Terms]) OR (recession)) OR (apical

displacement)) AND (((((papilla) OR (papillary)) OR (interproximal))
OR (midfacial)) OR (zenith))) OR (((aesthetics [MeSH Terms]) OR
(aesthetics, dental [MeSH Terms])) OR (aesthetics))))
Timing (((long term) OR (five years)) OR (ten years)))
The final search string included a combination of these search items as follows:
patient AND outcome AND timing. All studies were evaluated on their eligibility based
on inclusion and exclusion criteria as listed below. First, this was performed at title level,
then at abstract level. Articles that still qualified at the abstract level were printed and
full texts were read. Bibliographies of included articles as well as reviews were screened
for additional studies. If multiple publications were found on the same patient material,
only the publication with the longest follow-up was included.
129
Eligibility criteria
Inclusion criteria comprised:
• Human clinical studies published in English
• At least 18-year-old patients
• Systemically healthy patients
• Studies reporting on titanium implants
• Longitudinal studies (Randomized Controlled Trials (RCTs), cohort studies and case
series) on IIP
• Data on at least one outcome variable of interest (papillary changes, midfacial soft
tissue changes, peri-implant aesthetics)
• At least 10 cases at final study evaluation
• At least 5 years of follow-up
Studies were excluded on the basis of study design (case reports, letters to editors,
reviews).
Additional exclusion criteria were defined as studies:
• Reporting on zirconia implants
• Reporting on patients taking medications/therapy affecting bone metabolism (i.e.
bisphosphonates, radiation therapy)
• Reporting on patients with pathologies affecting bone metabolism (i.e. osteoporosis,
osteopenia, rheumathoid arthritis)
• Reporting on implants placed in sites affected by tumors
• Containing insufficient information on the surgical protocol and timing after tooth
extraction
RESULTS
Search results
The electronic search identified 240 articles. After exclusion of papers on the same
patient material, 9 studies were selected. Two studies were added following screening of
bibliographies, finally resulting in the inclusion of 11 publications.
Description of included studies

Clinical studies on IIP with at least 5 years of follow-up can be found in table 1. Most
studies were case series (Benic et al. 2012; Cooper et al. 2014; Fürhauser et al. 2017;
Noelken et al. 2018; Raes et al. 2018; Mura 2019; Seyssens et al. 2020). Two cohort studies
(Crespi et al. 2019; Covani et al. 2012) and 2 RCTs could also be identified (Canullo et
al. 2017; Slagter et al. 2021). Altogether, these studies provided long-term data on soft
tissue changes or peri-implant aesthetics from 637 implants installed in 437 patients.
In six studies only teeth with class I defects (Benic and Hammerle 2014) (intra-alveolar
bone defects) were included (Cooper et al. 2014; Canullo et al. 2017; Fürhauser et al. 2017;
Raes et al. 2018; Crespi et al. 2019; Seyssens et al. 2020), whereas in five studies also class
II defects (non-intact alveolar sockets) were included (Benic et al. 2012; Covani et al. 2012;
Noelken et al. 2018; Mura 2019; Slagter et al. 2021). Guided bone regeneration (GBR)
was performed to treat these bone defects in all but one study (Mura 2019). Soft tissue
grafting was only performed in a minority of cases by Seyssens and co-workers (2020).
Most studies reported on embrasure fill or papillary changes (Covani et al. 2012; Cooper
et al. 2014; Canullo et al. 2017; Raes et al. 2018; Mura 2019; Seyssens et al. 2020; Slagter
et al. 2021), and all but two (Noelken et al. 2018; Mura 2019) provided data on midfacial
soft tissue changes. Five studies described peri-implant aesthetics using an aesthetic
index (Fürhauser et al. 2017; Noelken et al. 2018; Raes et al. 2018; Seyssens et al. 2020;
Slagter et al. 2021). All but one (Slagter et al. 2021) used the original Pink Esthetic Score
(PES) by Fürhauser et al. (2005) resulting in a score from 0 (worst aesthetic outcome) to
14 (perfect aesthetic outcome). Slagter and co-workers (2021) used the modified PES by
Belser et al. (2009) resulting in a score from 0 (worst aesthetic outcome) to 10 (perfect
aesthetic outcome).
130
Table 1. Long-term soft tissue changes and peri-implant aesthetics of immediate implants.
Inclu-
N° im- Soft
sion of
Follow- Study plants/ tissue Embrasure fill or Midfacial soft Peri-implant
Author Study groups non- GBR
up design N° pa- graf- papillary changes tissue changes aesthetics
intact
tients ting
sockets
Benic
Pros case
et al. 7 years One group 14/14 Yes Yes No NR 1.5 mm* NR
series
2012
GBR cohort: 1.1

Covani GBR cohort Over half of mm°
Pros
et al. 10 years 159/91 Yes Yes No embrasure filled in NR
cohort Non-GBR cohort Non-GBR cohort:
2012 70% of the cases
0.7 mm°
Mesial papillary
Cooper recession: 0.13 mm
Pros case
et al. 5 years One group 45/45 No No No 0.06 mm recession NR
series Distal papillary
2014
recession: 0.21 mm
Test: platform Test: 0.21 mm Test: 0.23 mm

Canullo switching papillary gain overgrowth
et al. 10 years RCT 19/19 No Yes No NR
2017 Control: no plat- Control: 1.12 mm Control: 0.59 mm
form switching papillary recession recession
PES (/14)#:
Fürhauser
Pros case 12.6;
et al. 5 years One group 77/77 No No No NR 0.26 mm recession
series deterioration of
2017
alveolar process
PES (/14)#:
Noelken
Pros case 11.7;
et al. 5 years One group 33/19 Yes Yes No NR NR
series alveolar process
2018
scored worst
Mesial papillary PES (/14)#:

Raes recession: 0.44 mm
>8 Pros case 10.36;
et al. One group 11/11 No No No 0.09 mm recession
years series Distal papillary deterioration of
2018
recession: 0.27 mm alveolar process
Wide KM cohort
Wide KM
Crespi (≥ 2 mm) cohort: 0.15 mm
Pros overgrowth
et al. 5 years Narrow KM cohort 132/42 No No No NR NR
cohort
2019 (< 2 mm) Narrow KM cohort:
0.16 mm recession
At least half of the

Retro
Mura mesial and distal
10 years case One group 89/61 Yes No No NR NR
2019 embrasure filled in
series
96% and 88%, resp.
Yes, in 7 Mesial papillary PES (/14)#:

Seyssens gain: 0.03 mm
Pros case patients 10.61; alveolar
et al. 10 years One group 18/18 No Yes 0.58 mm recession
series at 3 Distal papillary process scored
2020
months recession: 0.22 mm worst
Test: mesial and

distal papillary Test: 1.44 mm
Test: immediate recession: 1.19 mm recession Test: PES
Slagter restoration and 1.18 mm, resp. (/10)§: 7.83
et al. 5 years RCT 40/40 Yes Yes No
2021 Control: delayed Control: mesial and Control: PES
restoration distal papillary Control: 0.81 mm (/10)§: 7.07
recession: 0.65 mm recession
and 1.20 mm, resp.
GBR: Guided Bone Regeneration including intra-alveolar socket grafting; Pros: Prospective; NR: Not reported; *:extrapolated value from cross-sectional evaluation after 7
years; °:position of the midfacial level apical to a reference line that connected the midfacial level of the adjacent teeth; RCT: Randomized Controlled Trial; #: Pink Esthetic
Score according to Fürhauser et al. 2005; KM: Keratinized mucosa; Retro: Retrospective; §: Pink Esthetic Score according to Belser et al. 2009.
131
Papillary changes
Covani and co-workers (2012) and Mura (2019) provided data on embrasure fill after 10
years of follow-up. In both studies the embrasure was (nearly) completely filled with a
papilla in the vast majority of cases. Limited shrinkage of the papilla well below 0.5 mm
has been described in a number of other long-term studies (Cooper et al. 2014; Canullo et
al. 2017; Raes et al. 2018; Seyssens et al. 2020). More papilla loss was observed by Slagter
and co-workers (2021). On the other hand, Canullo and co-workers (2017) and Seyssens
and co-workers (2020) reported slight papillary gain.
Midfacial soft tissue changes

Benic and co-workers (2012) and Covani and co-workers (2012) provided cross-sectional
data on the position of the midfacial soft tissue level at long-term follow-up. Although
these may be interesting from an explorative point of view, linear changes in midfacial
soft tissue levels are more relevant to consider as these relate to the initial situation. Such
data revealed midfacial recession varying from 0.06 mm (Cooper et al. 2014) to 1.44 mm
(Slagter et al. 2021) in the long term.
Peri-implant aesthetics
PES ranged from 10.36 to 12.6 in studies using the original PES (Fürhauser et al. 2017;
Noelken et al. 2018; Raes et al. 2018; Seyssens et al. 2020). “Alveolar process” was most
critical in all studies and deteriorated over time in two studies (Fürhauser et al. 2017;
Raes et al. 2018).
The aesthetic outcome in aforementioned studies corresponded well with a modified
PES of 7.07 - 7.83 as reported by Slagter and co-workers (2021). (Figure 1).
a) b) c)
d) e) f)
Figure 1.
a) 73-year-old male patient presenting with caries profunda on tooth 11; b) Intra-oral radiograph showing the extent of the lesion; c) Flapless extraction of 11, immediate
implant placement with surgical guide, socket grafting with deproteinized bovine bone mineral and connective tissue graft; d) Placement of provisional crown two
days following surgery; e) 3-month outcome with provisional crown in situ; f) 5-year outcome with permanent crown in situ. Note perfect soft tissue levels and buccal
convexity.
132
DISCUSSION
THE OBJECTIVE OF THIS CRITICAL REVIEW was to assess the long-term outcome of
IIP in terms of papillary changes, midfacial soft tissue changes and peri-implant aesthetics.
Since only 11 clinical studies could be identified reporting on at least one of these outcomes,
long-term data on soft tissue aspects of IIP are scarce.
In two articles embrasure fill was reported (Covani et al. 2012; Mura 2019).
Observational studies have shown that embrasure fill depends on the distance from the
bone crest to the contact point (Choquet et al. 2001) and the embrasure type (Cosyn et
al. 2013a). A complete papilla may be expected between an implant and tooth when the
distance from the bone crest to the contact point is 5 mm or less (Choquet et al. 2001),
which also applies to embrasures formed by adjacent teeth (Tarnow et al. 1992). When this
distance increases, the probability for complete fill of the embrasure decreases. Given this,
caution is needed with respect to evaluation of embrasure fill since an implant crown can
be made to any shape to close down the embrasure space. In that respect, linear changes
in papilla levels may be more valid and interesting to scrutinize. Most studies described
limited shrinkage of the papilla (Cooper et al. 2014; Canullo et al. 2017; Raes et al. 2018;
Seyssens et al. 2020). Only, Slagter and co-workers (2021) reported more papilla loss, which
could be explained by differences among the studies in registration methods and timing.
Altogether, papillae may not represent a major concern following IIP, especially when
flapless implant surgery is performed and when contact points are properly positioned.
Apart from one study (Slagter et al. 2021), all studies reported acceptable midfacial
recession below 0.6 mm. It is important to realize that these are mean values, which can
be misleading for the individual patient. In this respect, frequency distributions are more
relevant to consider, yet these are seldom reported. Sometimes, these reveal high risk of
midfacial recession even when mean values are low or acceptable. Indeed, 21% of the cases
in the study of Cooper and co-workers (2014) demonstrated ≥ 1 mm midfacial recession,
whereas mean midfacial recession was only 0.06 mm. Similarly, 33% of the cases in the
study of Seyssens and co-workers (2020) showed ≥ 1 mm midfacial recession with mean
midfacial recession pointing to 0.58 mm. Most interestingly, Seyssens et al. (2020) reported
on the 10-year outcome of IIP. The one- and 5-year outcomes of this patient cohort have
been published before (Cosyn et al. 2013b; Cosyn et al. 2016) and show slight deterioration
of midfacial soft tissue levels over time. This has also been described by Kan and co-
workers (Kan et al. 2003; Kan et al. 2011) and may not support perfect stability of midfacial
soft tissue levels in the long-term following IIP. To what extent these findings relate to
underlying changes of the buccal bone wall is unclear, but immediate implants without any
buccal bone have been described and associated with midfacial recession (Benic et al. 2012;
Seyssens et al. 2020).
Several putative risk factors for midfacial recession have been described and enable
clinicians to anticipate, which could make IIP more predictable. Availability of bone (Kan
et al. 2007) and keratinized tissue (Crespi et al. 2019) at the time of implant placement are
critical factors. The most important risk factor for midfacial recession is probably a buccal
shoulder position (Seyssens et al. 2020). Therefore, state-of-the-art IIP should include
guided implant placement (Smitkarn et al. 2019). In addition, socket grafting has shown to
reduce buccal bone remodeling following IIP (Chen et al. 2007; Sanz et al. 2017; Girlanda
et al. 2019), which could have a positive impact on midfacial soft tissue levels (Cardaropoli
et al. 2014; Bittner et al. 2020). Finally, a recent systematic review has shown 0.4 mm less
midfacial recession when a connective tissue graft is applied at the buccal aspect (Seyssens
et al. 2021). Especially when elevated risk for midfacial recession is expected in the
aesthetic zone (thin gingival biotype, < 0.5 mm buccal bone thickness), a connective tissue
graft at the buccal aspect appears beneficial to improve soft tissue stability. A clinical case is
shown in figure 1 combining these approaches.
133
Cosyn and co-workers (2012b) arbitrarily defined PES ≥ 12 as an (almost) perfect

peri-implant aesthetic outcome, and PES < 8 as an aesthetic failure. PES was well above
10 in all studies using the original PES (Fürhauser et al. 2017; Noelken et al. 2018; Raes
et al. 2018; Seyssens et al. 2020), indicative of an overall acceptable aesthetic outcome for
IIP in the long term. Interestingly, “alveolar process” was most critical in all studies and
deteriorated over time in two studies (Fürhauser et al. 2017; Raes et al. 2018). Once again,
these findings suggest underlying changes of the buccal bone wall in the long term.
For a correct interpretation of the results of this critical review, the following limitations
should be taken into account. First, this is not a systematic review using multiple databases,
which could have had an impact on the selection of studies and the weight of a study
within the body of evidence. In addition, risk of bias assessment is an important part of a
systematic review and such qualitative evaluation was not performed here. Second, included
studies reported on immediate implants installed by trained clinicians. More variability in
patient selection and implant placement can be expected in clinical practice and therefore,
inferior clinical and aesthetic outcomes than the ones presented in this review are plausible.
In conclusion, limited soft tissue changes and acceptable aesthetics have been described
for IIP in the long term, although loss of buccal convexity seems common. These findings
pertain to patients who were treated by experienced clinicians. Stringent case selection,
meticulous implant placement, hard and soft tissue grafting are key elements for stable soft
tissues and favorable aesthetics in the long term.
CLINICAL RELEVANCE
ALTHOUGH LIMITED SOFT TISSUE CHANGES and acceptable aesthetics
have been described for IIP in the long term, loss of buccal convexity seems a
common finding. Therefore, clinicians should consider soft tissue grafting as an
adjunct to IIP to increase soft tissue volume. In addition, soft tissue grafting has
also shown to improve midfacial soft tissue stability.
SOFT TISSUE GRAFTING may increase buccal soft tissue volume and improves
midfacial soft tissue stability following IIP. However, the need for soft tissue
grafting as an adjunct to IIP or other treatment concepts has never been
thoroughly studied. Randomized controlled trials are needed to compare the need
for soft tissue grafting between various implant placement protocols.
134
Araújo MG, Sukekava F, Wennstrom JL, Lindhe J. (2005) Cosyn J, Eghbali A, De Bruyn H, Dierens M, De Rouck T. Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman
Ridge alterations following implant placement in (2012b) Single implant treatment in healing versus G. (2011) Facial gingival tissue stability following
fresh extraction sockets: An experimental study in healed sites of the anterior maxilla: An aesthetic immediate placement and provisionalization of
the dog. Journal of Clinical Periodontology 32, 645- evaluation. Clinical Implant Dentistry and Related maxillary anterior single implants: A 2- to 8-year
652. Research 14, 517-526. follow-up. The International Journal of Oral and
Benic GI, Mokti M, Chen CJ, Weber HP, Hammerle Cosyn J, Raes M, Packet M, Cleymaet R, De Bruyn Maxillofacial Implants 26, 179-187.
CH, Gallucci GO. (2012) Dimensions of buccal H. (2013a) Disparity in embrasure fill and papilla Lin GH, Chan HL, Wang HL. (2014) Effects of currently
bone and mucosa at immediately placed implants height between tooth- and implant-borne fixed available surgical and restorative interventions on
after 7 years: A clinical and cone beam computed restorations in the anterior maxilla: A cross-sectional reducing midfacial mucosal recession of immediately
tomography study. Clinical Oral Implants Research study. Journal of Clinical Periodontology 40, 728- placed single-tooth implants: A systematic review.
23, 560-566. 733. Journal of Periodontology 85, 92-102.
Benic GI, Hammerle CH. (2014) Horizontal bone Cosyn J, De Bruyn H, Cleymaet R. (2013b) Soft Mura P. (2019) Immediate placement of tapered
augmentation by means of guided bone tissue preservation and pink aesthetics around implants with a moderately rough anodized surface
regeneration. Periodontology 2000 66, 13-40. single immediate implant restorations: A 1-year and smooth collar in fresh extraction sockets: A
Belser UC, Grutter L, Vailati F, Bornstein MM, Weber prospective study. Clinical Implant Dentistry and retrospective analysis with 10-year follow-up. Clinical
HP, Buser, D. (2009) Outcome evaluation of early Related Research 15, 847-857. Implant Dentistry and Related Research 21, 272-277.
placed maxillary anterior single-tooth implants Cosyn J, Eghbali A, Hermans A, Vervaeke S, De Bruyn Noelken R, Moergel M, Kunkel M, Wagner W. (2018)
using objective esthetic criteria: A cross-sectional, H, Cleymaet, R. (2016) A 5-year prospective study Immediate and flapless implant insertion and
retrospective study in 45 patients with a 2- to 4-year on single immediate implants in the aesthetic zone. provisionalization using autogenous bone grafts
follow-up using pink and white esthetic scores. Journal of Clinical Periodontology 43, 702-709. in the esthetic zone: 5-year results. Clinical Oral
Journal of Periodontology 80, 140-151. Cosyn J, De Lat L, Seyssens L, Doornewaard R, Implants Research 29, 320-327.
Bittner N, Planzos L, Volchonok A, Tarnow D, Deschepper E, Vervaeke, S. (2019) The effectiveness Raes S, Eghbali A, Chappuis V, Raes F, De Bruyn H,
Schulze-Spate U. (2020) Evaluation of horizontal of immediate implant placement for single Cosyn, J. (2018) A long-term prospective cohort
and vertical buccal ridge dimensional changes tooth replacement compared to delayed implant study on immediately restored single tooth implants
after immediate implant placement and placement: A systematic review and meta-analysis. inserted in extraction sockets and healed ridges:
immediate temporization with and without bone Journal of Clinical Periodontology 46 Suppl 21, CBCT analyses, soft tissue alterations, aesthetic
augmentation procedures: Short-term, 1-year 224-241. ratings, and patient-reported outcomes. Clinical
results. a randomized controlled clinical trial. The Covani U, Cornelini R, Barone, A. (2007) Vertical crestal Implant Dentistry and Related Research 20, 522-
International Journal of Periodontics & Restorative bone changes around implants placed into fresh 530.
Dentistry 40, 83-93. extraction sockets. Journal of Periodontology 78, Sanz M, Lindhe J, Alcaraz J, Sanz-Sanchez I, Cecchinato
Botticelli D, Berglundh T, Lindhe J. (2004) Hard-tissue 810-815. D. (2017) The effect of placing a bone replacement
alterations following immediate implant placement Covani U, Chiappe G, Bosco M, Orlando B, Quaranta A, graft in the gap at immediately placed implants:
in extraction sites. Journal of Clinical Periodontology Barone A. (2012) A 10-year evaluation of implants A randomized clinical trial. Clinical Oral Implants
31, 820-828. placed in fresh extraction sockets: A prospective Research 28, 902-910.
Canullo L, Caneva M, Tallarico M. (2017) Ten-year cohort study. Journal of Periodontology 83, 1226- Seyssens L, Eghbali A, Cosyn J. (2020) A 10-year
hard and soft tissue results of a pilot double-blinded 1234. prospective study on single immediate implants.
randomized controlled trial on immediately loaded Crespi R, Cappare P, Crespi G, Gastaldi G, Romanos Journal of Clinical Periodontology 47, 1248-1258.
post-extractive implants using platform-switching GE, Gherlone E. (2019) Midfacial tissue assessment Seyssens L, De Lat L, Cosyn J. (2021) Immediate implant
concept. Clinical Oral Implants Research 28, 1195- of the effect of amount of keratinized mucosa on placement with or without connective tissue graft:
1203. immediate temporarization of fresh socket implants: A systematic review and meta-analysis. Journal of
Cardaropoli D, Gaveglio L, Gherlone E, Cardaropoli G. 8-year follow-up. The International Journal of Clinical Periodontology 48, 284-301.
(2014) Soft tissue contour changes at immediate Periodontics & Restorative Dentistry 39, 227-232. Smitkarn P, Subbalekha K, Mattheos N, Pimkhaokham
implants: A randomized controlled clinical study. The Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, A. (2019) The accuracy of single-tooth implants
International Journal of Periodontics & Restorative Watzek G. (2005) Evaluation of soft tissue around placed using fully digital-guided surgery and
Dentistry 34, 631-637. single-tooth implant crowns: The pink esthetic freehand implant surgery. Journal of Clinical
Chen ST, Darby IB, Reynolds, EC. (2007) A prospective score. Clinical Oral Implants Research 16, 639-644. Periodontology 46, 949-957.
clinical study of non-submerged immediate Fürhauser R, Mailath-Pokorny G, Haas R, Busenlechner Slagter KW, Raghoebar GM, Hentenaar DFM, Vissink
implants: Clinical outcomes and esthetic results. D, Watzek G, Pommer B. (2017) Immediate A, Meijer HJA. (2021) Immediate placement
Clinical Oral Implants Research 18, 552-562. restoration of immediate implants in the esthetic of single implants with or without immediate
Chen ST, Buser D. (2014) Esthetic outcomes zone of the maxilla via the copy-abutment provisionalization in the maxillary aesthetic region:
following immediate and early implant placement technique: 5-year follow-up of pink esthetic scores. A 5-year comparative study. Journal of Clinical
in the anterior maxilla: A systematic review. The Clinical Implant Dentistry and Related Research 19, Periodontology 48, 272-283.
International Journal of Oral and Maxillofacial 28-37. Tarnow DP, Magner AW, Fletcher P. (1992) The
Implants 29 Suppl, 186-215. Girlanda FF, Feng HS, Correa MG, Casati MZ, Pimentel effect of the distance from the contact point to
Choquet V, Hermans M, Adriaenssens P, Daelemans SP, Ribeiro FV, Cirano FR. (2019) Deproteinized the crest of bone on the presence or absence
P, Tarnow DP, Malevez C. (2001) Clinical and bovine bone derived with collagen improves soft and of the interproximal dental papilla. Journal of
radiographic evaluation of the papilla level adjacent bone tissue outcomes in flapless immediate implant Periodontology 63, 995-996.
to single-tooth dental implants. A retrospective approach and immediate provisionalization: A Tonetti MS, Jung RE, Ávila-Ortiz G, Blanco J, Cosyn
study in the maxillary anterior region. Journal of randomized clinical trial. Clinical Oral Investigations J, Fickl S, Figuero E, Goldstein M, Graziani F,
Periodontology 72, 1364-1371. 23, 3885-3893. Madianos P, Molina A, Nart J, Salvi GE, Sanz-Martín
Cooper LF, Reside GJ, Raes F, Garriga JS, Tarrida LG, Kan JY, Rungcharassaeng K, Lozada J. (2003) Immediate I, Thoma D, van Assche N, Vignoletti F. (2019)
Wiltfang, J, Kern M, De Bruyn H. (2014) Immediate placement and provisionalization of maxillary Management of the extraction socket and timing
provisionalization of dental implants placed in anterior single implants: 1-year prospective study. of implant placement: Consensus report and clinical
healed alveolar ridges and extraction sockets: A The International Journal of Oral and Maxillofacial recommendations of group 3 of the XV European
5-year prospective evaluation. The International Implants 18, 31-39. Workshop in Periodontology. Journal of Clinical
Journal of Oral and Maxillofacial Implants 29, 709- Kan JY, Rungcharassaeng K, Sclar A, Lozada JL. (2007) Periodontology 46 Suppl 21, 183-194.
717. Effects of the facial osseous defect morphology Vignoletti F, de Sanctis M, Berglundh T, Abrahamsson
Cosyn J, Hooghe N, De Bruyn H. (2012a) A systematic on gingival dynamics after immediate tooth I, Sanz M. (2009) Early healing of implants placed
review on the frequency of advanced recession replacement and guided bone regeneration: 1-year into fresh extraction sockets: An experimental study
following single immediate implant treatment. results. Journal of Oral and Maxillofacial Surgery 65, in the beagle dog. II: Ridge alterations. Journal of
Journal of Clinical Periodontology 39, 582-589. 13-19. Clinical Periodontology 36, 688-697.
135
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Studies show the efficacy of the rubber GINGIVAL ABRASION RESULTS

interdental pick and the interdental Overall mean gingival abrasion scores in
brush in reducing plaque and bleeding, marginal, interdental, and mid-gingival areas.
although the interdental pick seems
to be associated with less bleeding and interdental brushes rubber interdental picks
abrasion, as well as a greater patient
acceptance. 14.81
13.88
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I found the use

(0 = very unpleasant, 10 = very pleasant)
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0 1 2 3 4 5 6 7 8 9 10
interdental brushes rubber interdental picks T0 T21 WEEK 1 WEEK 2 WEEK 4
EXPERIMENTAL PHASE TREATMENT PHASE

I found it scary to use
(0= not at all, 10= yes very much)
*After 4 weeks, the difference in GA between IDBs (14.81) and RIPs
(Hennequin-Hoenderdos 2018) (11.5) was statistically significant (p = 0.001) in favor of the RIPs.
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Dentsply Sirona
Comparison of plaque and gingivitis
interest
reduction Using a new toothbrush with
O-R technology and a toothbursh with
sonic and lateral oscillating technology.
Six-month randomized clinical trial
to
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Immediate implant stabilized in
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New Nobel Biocare N1 osteotomy
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SCIENTIFIC ARTICLES OF INTEREST TO BUSINESSES
IMMEDIATE IMPLANT AND IMMEDIATE PROVISIONALIZATION OF AN

OSSEOSPEED® EV IMPLANT USING AN ACURIS CONOMETRIC ABUTMENT.
A PARADIGM SHIFT IN PROSTHETIC RETENTION FOR SINGLE
TOOTH RESTORATIONS.
DR. PELAYO ANTUÑA.
A 61-year old patient came to the

office due to the fracture of her first
premolar.
We decided to perform an Figure 5. After the connection of an Acuris Figure 11. At this point the Conometric Impression
Conometric Abutment (3,6/2.0º/4.5/l) we snapped Cap was inserted aligned to the indexing part of
immediate implant placement on the Conometric Temporization Cap. the abutmentandand snapped into place.
followed by an immediate
provisional restoration using an
AcurisConometricabutment.
Acurisis a cement free retention
system that provides fix retention
but the prosthesis stills yet
retrievable by the clinician.
Figure 6. The implant was loaded with a Figure 12. Before inserting the final crown we
provisional restoration that was relined intaroraly checked the contact points and the occlusion using
to the Conometric Temporization Cap and the Conometric Lab Cap fixed to the crown with a
polished all finished extraoraly. cyanoacrylate.
Figure 1. Aspect of the alveolus after the Figure 7. Control X-Ray of the immediate implant Figure 13. This was the spect of the final crown
atraumatic extraction. and the provisional restoration. fixed to the Conometric Lab Cap.
Figure 2. A 3,6X11 OsseoSpeed® EV implant was Figure 8. We waited 2,5 months for the Figure 14. Once verified that everything was
inserted transalveolary. osseointegration of the fixture before the final correct the final crown was cemented to the
impressions. Conometric Final Cap extraoraly.
Figure 3. The implant was anchored to the palatal Figure 9. This was the aspect of the tissues after
wall of the alveolus. the removal of the provisional restoration. There
is no evidence of inflammation.
Figure 15. The final restoration was inserted using
the Conometric Fixation Tool in order to activate
the friction retention.
Figure 4. The buccal wall of the alveolus was Figure 10. Occlusal view of the Conometric
Case courtesy of
grafted with a xenograft stabilized by the abutmentand the proper contoured soft tissues. Dr. Pelayo Antuña
provisional restoration.
141
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COMPARISON OF PLAQUE AND GINGIVITIS REDUCTION

USING A NEW TOOTHBRUSH WITH O-R TECHNOLOGY AND A
TOOTHBURSH WITH SONIC AND LATERAL OSCILLATING TECHNOLOGY.
SIX-MONTH RANDOMIZED CLINICAL TRIAL.
RESULTS reduction in gingivitis and plaque
BIBLIOGRAPHICAL REFERENCE A significantly greater proportion than was achieved with a model
Goyal CR, Adam R, Timm H, Grender J,
of subjects in the group that used of an advanced sonic toothbrush,
Qaqish J. (2021) A 6-month randomized the oscillating-rotating toothbrush both used in the mode of smart
controlled trial evaluating a novel went from an “unhealthy” to a connection over six months. More
smart-connected oscillating-rotating “healthy” gingival state in week users of the OralB® iO moved to
toothbrush versus a smart-connected 24, compared to the group that a “generally healthy” gingival
sonic toothbrush for the reduction of used the sonic toothbrush (96.4 %
plaque and gingivitis. American Journal state (< 10% points of bleeding,
compared with 81.8 %; p = 0,029).
of Dentistry 34, 54-60. according to the classification
The subjects who used the Oral-B®
iO toothbrush also had more of gingival and periodontal
probability of moving to a healthy disease by the World Workshop)
AIM compared with the users of the
gingival state – with a probability
This study of six months duration sonic toothbrushes. In addition,
3.9 times greater in the first week
compared the effects on the and 5.9 times greater in the sixth the subjects who used OralB® iO
reduction of gingivitis and plaque month – than those who used the had more probability of moving
of a rechargeable oscillating- sonic toothbrush. to a “generally healthy” gingival
rotating (O-R) electric toothbrush The oscillating-rotating state than those using the sonic
with microvibrations and position toothbrush achieved a significantly toothbrush, even from the first
detection through artificial greater reduction in the adjusted week.
intelligence with those of a measurements of MGI, GBI, and These results show that the
rechargeable sonic toothbrush. the adjusted average number of greater reductions of plaque
bleeding points than the sonic and gingivitis achieved with
METHOD toothbrush (week 24, 32.6& in OralB® iO against Sonicare
In this randomized, single- MGI, 23.7% in GBI, and 26.1% DiamondClean – shown in an
blind study, 110 adult subjects in the number of bleeding points, earlier eight-week study that did
who presented gingivitis and p < 0.001).
not include smart connectivity
plaque were studied. They were From day one until month
– have been maintained over a
distributed randomly into a six, Oral-B® iO achieved
statistically significant reductions significantly longer study period,
group that used the oscillating- of six months, which suggests that
in plaque compared to Sonicare
rotating toothbrush (Oral-B ® iO) the smart connectivity or OralB®
DiamondClean in the areas of
and another group that used the plaque in the whole oral cavity, iO contributes to maintaining
sonic toothbrush (Philips Sonicare interproximal, and in the gingival benefits for oral health over time.
DiamondClean). Both groups were margins (p ≤ 0.007). These results also coincide with
told to brush twice a day using a In comparison with the sonic those obtained in the published
normal toothpaste with sodium toothbrush, in the sixth month, meta-analysis, which showed
fluoride, and the subjects were Oral-B® iO removed: greater benefits for gingival
helped to download and install • 24.6 % more plaque in the health from the use of oscillating-
the application, indicating that whole oral cavity; rotating toothbrushes compared
they should use it according to the • 25.8 % more interproximal with various sonic toothbrushes.
instructions of each manufacturer. plaque; and Specifically, the benefits for
The plaque and gingivitis values • 61.9 % more plaque along the gingival health shown by the
gum line. OralB® iO on the lingual surfaces
were evaluated initially and in the
first and 24th weeks, using the CONCLUSIONS suggest that the round head is the
modified gingival index (MGI), In this randomized clinical most appropriate for cleaning of
the gingival bleeding index (GBI), trial, OralB® iO demonstrated a the lingual zones, which are often
and the Rustogi modified plaque statistically significant greater neglected.
index (RMPI). The classification
of the gingival state as “healthy” 26.1% more
Adjusted average reduction from basal
reduction 96.4
or “unhealthy” was made in 25 100
point: Nº. of bleeding points
accordance with the definitions 81.8

% subjects classified
20 80
of periodontal and peri-implant
diseases established at the World 44.9%
as healthy
15 60
more
Workshop of the Classification reduction
10 40
of Periodontal and Peri-implant
Diseases and Conditions. All 110 18.2
5 20
subjects completed the study; the 5.5
0 0
average age was 46.2 years and Week 1 Month 6 Week 1 Month 6
69 % were women.
Oral-B iO Sonic Oral-B iO Sonic
143
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IMMEDIATE IMPLANT STABILIZED IN MANDIBULAR BONE SEPTUM.
NEW NOBEL BIOCARE N1 OSTEOTOMY DRILLING PROTOCOL.
ALFONSO CABALLERO DE RODAS RAMÍREZ.
The new Nobel Biocare We inserted the 13 mm N1 RP

BIBLIOGRAPHICAL REFERENCES osteotomy drilling protocol, using implant, achieving a final torque of
Chen CH, Coyac BR, Arioka M, Leahy a single burr, facilitates the 40 Nw, and we filled the alveolar
B, Tulu US, Aghvami M, Holst S, placement of immediate implants in gap with the creos™ xenograft
Hoffmann W, Quarry A, Bahat O, extraction sockets, saving surgical
Salmon B, Brunski JB, Helms JA.
biomaterial.
(2019) A Novel osteotomy preparation
time and preserving the aesthetics
of the soft tissues. RESULTS
technique to preserve implant site
viability and enhance osteogenesis. The result in this case was very
Journal of Clinical Medicine 8, 170. AIMS good, achieving a complete alveolar
The aim of this article is to show regeneration, preserving both the
Velikov S, Camenzind M, Fabech J, Fuchs
the placement of an implant in a
F. (2020) Stability of a new trioval aesthetics of the tissues and their
implant in bone surrogate model. post-extraction socket using the
normal bone volume.
Journal of Dental Research 99, 3052. new Nobel Biocare N1 osteotomy
Restoration was made with a
Yin X, Li J, Hoffmann W, Gasser A, Brunski drilling protocol, as well as its final
cemented screwed zirconium crown
JB, Helms JA. (2019) Mechanical and restoration.
Biological Advantages of a Tri-Oval
on a universal abutment, screwed
Implant Design. Journal of Clinical MATERIALS Y METHODS at 20 Nw.
Medicine 8, 1-13. The 27-year-old patient, non-
smoker and with no relevant DISCUSSION
Velikov S, Susin C, Heuberger P,
medical history, presented a tooth The placement of immediate post-
Irastorza-Landa A. (2020) A New site
preparation protocol that supports 85 with agenesis of a definitive extraction implants is complex
bone quality evaluation and provides tooth. because of the alveolar anatomy
predictable implant insertion torque. or the bone destruction provoked
Journal of Clinical Medicine 9, 494. SURGICAL TECHNIQUE
by the tooth’s previous pathology.
Grunder U, Polizzi G, Goene R, Hatano An atraumatic extraction of the
Furthermore, alveolar remodelling
N, Henry P, Jackson WJ, Kawamura K, deciduous tooth 85 was made, with
after the extraction can provoke
Köhler S, Renouard F, Rosenberg R, curettage of the granulation tissue
Triplett G, Werbitt M, Lithner B. (1999) a decompensation of the soft and
provoked by the destruction of the
A 3 year prospective multicenter
tooth. hard tissues, compromising the
follow-up report on the immediate
Once the alveolar socket had aesthetics of our implants.
and delayed immediate placement
of implants. The International Journal been cleansed, we started the On many occasions, it
of Oral and Maxillofacial Implants 14, preparation of the implant bed with is preferable to wait for the
210-216. spontaneous regeneration of the
the first burr of the N1 protocol
Tolman DE, Keller EE. (1991) Endosseous (OsseoDirector 1™) at high speed alveolar process and place the
implant placement immediately implants in a deferred way after
and with irrigation.
following dental extraction and
alveoloplasty: Preliminary report Using a probe, we measured the three months.
within 6-year follow-up. The depth of the drilling and selected
CONCLUSION
International Journal of Oral and the length of the implant. In this
Maxillofacial Implants 6, 24-28. The placement of immediate
case, we used a Nobel Biocare N1
implants has a high success
platform RP (4.0 mm) implant, with
rate. According to different
a length of 13 mm.
We opened the case of authors, it is between 92.7% and
our implant and used the 98.0%. In addition, only a single
OsseoShaper1™ burr for the RP surgical act is used for implant
INTRODUCTION implant of 13 mm. We drilled at low placement, reducing the time of the
Given the anatomical complexity revolutions (40 rpm) and without spontaneous bone regeneration.
of the inferior molars, the irrigation in a clockwise direction The patient should be selected,
stabilization of implants in the and, once the full length had been carrying our diagnostic tests and
bone septum is complicated in most reached, we unscrewed in an anti- proceeding carefully to a surgical
cases. clockwise direction. technique.
144
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Reshaping
Nobel Biocare N1™
IMPLANTOLOGY
together
nobelbiocare.com/n1
GMT70838 © Nobel Biocare Services AG, 2020. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in
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purposes only and may not be an exact representation of the product. Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare
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BEXIDENT® POST:
UPDATE ON CLINICAL EVIDENCE (IN VITRO AND IN VIVO).
Recently, various independent controlled trial with placebo that
BIBLIOGRAPHICAL REFERENCES studies have evaluated its anti- included 36 patients (72 teeth)
Gargallo J. et al. (2009) Demostración inflammatory and antibacterial in which extractions of impacted
in vitro del efecto cicatrizante y inferior bilateral third molars
activity (in vitro) (Torres-Rosas
antiinflamatorio de un gel gingival.
Póster presentado en el VII Congreso et al. 2020), as well as its clinical were performed. The parameters
Nacional de la Sociedad Española de efficacy (in vivo) in the control of evaluated at base and after
Cirugía Bucal. Almería.
pain and inflammation in surgery seven days were: the presence
López-López J, Jan-Pallí E, González, of inflammation, trismus, post-
on the third molar (Torres-Rosas et
B, Jané-Salas E. (2015) Efficacy of
clorhexidine, dexpanthenol, allantoin al. 2020; Sáez-Alcaide et al. 2020). operative pain and analgesic
and chitosan gel in comparison with The first of these is an in control, wound healing, and the
bicarbonate oral rinse in controlling presence of complications (Sáez-
post-interventional inflammation, vitro study whose aim was to
pain and cicatrization in subjects evaluate BP’s antibacterial Alcaide et al. 2020).
undergoing dental surgery. Current activity, cytotoxic activity, and the The results showed that 13.9 %
Medical Research and Opinion 31,
1-6. expression of prostaglandin E2. of the patients who received the
To this end, the following were placebo presented alveolitis, while
Torres-Rosas R, Torres-Gómez N, Moreno-
Rodríguez A, García-Contreras R, evaluated: 1) the antimicrobial no one in the experimental group
Argueta-Figueroa L. (2020) Anti- activity (minimal bactericidal and did (p = 0,063). In relation to the
inflammatory and antibacterial
inhibitory concentrations) against presence of swelling or trismus,
activity of the chitosan/chlorhexidine
gel commercial preparation for Staphylococcus aureus, Escherichia significantly lower values were
postexodontia treatment: An in vitro
coli, and Streptococcus mutans; observed in the experimental
Study. European Journal of Dentistry
14, 397-403. 2) the cytotoxicity (loss of viable group compared to the control
cells in various cell cultures) using group. Seven days after surgery
Sáez-Alcaide LM, Molinero-Mourelle P,
González-Serrano J, Rubio-Alonso L, tetrazolium colouring; and 3) the the healing of the surgical wound
Bornstein MM, López-Quiles J. (2020)
expression of PGE2 using ELISA was considered “good” in 97.2 %
Efficacy of a topical gel containing
(Torres-Rosas et al. 2020). of the experimental group but in
chitosan, chlorhexidine, allantoin
and dexpanthenol for pain and only 22.2 % of the control group
The results obtained showed
inflammation control after third molar (p < 0.001). Finally, in terms of
surgery: A randomized and placebo- minimal bactericidal concentrations
pain control, the average score
controlled clinical trial. Medicina Oral of 25 %, 50 %, and 12.5 % against
Patologia Oral y Cirugia Bucal 25, using the visual analogue scale
e644-e651.
S. aureus, E. coli, and S. mutans
(VAS) was statistically lower in
respectively, while the minimal
the experimental group compared
inhibitory concentrations for the
to the placebo group (p = 0.002);
same strains were 12.5 %, 25 %,
furthermore, the average
and 3.125 %. On the other hand,
Thanks to its innovative consumption of analgesics in the
an average cytotoxic concentration
combination of chitosan and first days was statistically lower
(CC50) of 12.5 ± 1.09 was observed
chlorhexidine at 0.2 % (Chitoheal in the patients of the experimental
Tech® technology), Bexident® POST in the bone cellular culture, of
group (p = 0.003) (Sáez-Alcaide et
from ISDIN provides a triple action 9.8 ± 0.01 in the cellular cultures of
al. 2020).
(healing, antiseptic, and anti- the dental pulp, and of 8.2 ± 0.08 in
It is known today that the
inflammatory), which accelerates the culture of the human gingival
postsurgical treatment of the
the postintervention recovery. fibroblast. Finally, the production of
oral cavity is key to ensuring the
Clinical evidence that PGE2 was inversely dose-dependent
success of periodontal and peri-
supports the efficacy of in the various dilutions of the BP
implant procedures. Bexident®
Bexident® POST (BP) has been gel (Torres-Rosas et al. 2020).
POST, with its triple action
evaluated in various clinical With these results, it can be and with more than a million
studies that have shown its considered that the BP gel provides patients treated, continues
reparatory and healing action an antibacterial effect and an to demonstrate its clinical
increasing cellular proliferation adequate biocompatibility (showing efficacy and its leadership in
(89 %) and collagen synthesis a reduction in the expression of postsurgical treatment*.
(31 %) (Gargallo et al. 2009), as PGE2). Because of this, its use as a
well as its anti-inflammatory cicatrizing agent after oral surgery
* Units sold of Bexident Post and of
action that reduces seems appropriate. products with a regenerative, antiseptic,
inflammation (50 %), reducing On the other hand, Sáez- and anti-inflammatory effect in Spain,
Portugal, and Mexico from September
the consumption of analgesics Alcaide et al. (2020) carried 2009 to December 2019. Estimate 1 unit
(46 %) (López-López et al. 2015). out a double-blind, randomized sold = 1 patient treated.
146
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EXPLANTATION OF IMPLANTS USING

PIEZOELECTRIC SURGERY QAND REVERSE TORQUE.
PROF. JORGE EDUARDO DELGADO PEÑA.
MATERIALS AND METHODS RESULTS

BIBLIOGRAPHICAL REFERENCE A 42-year-old patient without The implant was removed thanks to
Carini F, Saggese V, Porcaro G, Baldoni relevant medical history, with the combination of two conservative
M.(2014) Piezolelectric surgery no previous pathology, and a techniques to reduce surgical
in dentistry: a review. Minerva non-smoker, attended the clinic trauma, diminish the excessive
Stomatologica 63, 7-34. because of an implant in the removal of bone, and prevent
position of tooth 14. The implant damage to the connection of the
had been functioning for 10 years. implant.
The clinical examination showed
INTRODUCTION a cemented restoration (mental- DISCUSSION
Piezoelectric surgery presents great ceramic crown with ceramic gum, The explantation of implants is
versatility for various applications Figure 1). The incisor-cervical necessary when problems of bad
in oral surgery, periodontics, and dimension of the crown was very positioning cannot be corrected
implantology. The possibility of large and inflammation and with prosthetic techniques or when
using different grafts allows, among gingival bleeding was observed. The a severe biological compromise
other things, the realization of radiographic examination did not is present. In this case, although
sagittal osteotomies, the removal show bone loss. After completing the the implant functioned for 10
of localized bone, the opening of evaluation of the restorative options years, it was considered that its
the wall of the maxillary sinus, and discussion with the patient, it bad vertical position was the
atraumatic tooth extraction, was decided to explant the implant. cause of the aesthetic failure and
elevation of the sinus membrane, The procedure was performed with
at the same time was generating
preparation of the implant bed, local anaesthetic. A full-thickness
a biological complication. The
odontosection, and the removal of trapezoidal flat was raised (Figure
conventional explantation
2), a screw with inverted thread for
implants. In addition, the technique techniques for dental implants
implant explantation was inserted
produces a selective and precise cut use trephines, surgical burrs, and
and reverse torque was applied
(controllable with the appropriate implant transporters with reverse
until reaching a torque of 89 Ncm
selection of the graft), control of without success. To avoid damage torque. During the execution of the
bleeding in the operative zone to the connection, fracture of the first two techniques, the excess of
(produced by constant irrigation implant, and the surgical trauma bone tends to be removed,which
and the phenomenon of cavitation), of a surgery with trephine burr, it increases the deficiency of bone
low inflammatory response, and less was decided to perform minimal volume in the zone. The technique
post-operative pain compared with peri-implant osteotomy with of transporters with reverse torque
conventional osteotomy techniques piezoelectric surgery. The technique is not efficient in cases of implants
(through the reduction of surgical of sequential piezosurgery was that are completely osteointegrated
trauma and the presence of a used. First the LCI insert (Acteon, and can fracture the implant. The
greater number of viable osteocytes Figure 3) was used creating a combination of the two techniques
after the ultrasonic piezoelectric groove parallel to the walls of the allows the atraumatic explantation
surgery). implant and the LC2 insert (Figure of the implant to be completed.
4) was then used to increase the
AIMS dimensions of the osteotomy. Then, CONCLUSIONS
To present a clinical case where a the implant-explantation screw Piezoelectric surgery combined with
badly positioned dental implant was was introduced again (Figure 5) implant transporters and reverse
explanted combining the techniques and, applying a reverse torque of 40 torque allows the atraumatic
of piezoelectric surgery and reverse Ncm, removal of the implant was explantation of badly positioned
torque. achieved (Figure 6). implants.
Prof. Jorge Delgado
Prof. Jorge Delgado

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153
NEW FRONTIERS IN Periodoncia Clínica Conclusions
FROM MYTH TO A CONCRETE AND

PREDICTABLE CLINICAL REALITY:
NEW HORIZONS IN IMMEDIATE
IMPLANTSS.
FABIO VIGNOLETTI AND JAN COSYN, GUEST EDITORS OF PERIODONCIA CLÍNICA N.º 20
I HAVE HAD THE IMMENSE Furthermore, we publish original articles by a series of

PLEASURE and honour of national and international authors who have written the main
receiving the invitation from my pages of the history of immediate implants. We start with the
dear friend, colleague, and editor group of Dr Paulo Fernando Mezquita and Dr José Carlos Martins
of this magazine, Dr. Ignacio Sanz da Rosa, both pioneers in the treatment of implants in type II and
Martín, to participate as a national guest editor together with II alveolar sockets, with the GBR technique and tuberosity insert,
Prof. Jan Cosyn (international guest editor) in the preparation respectively. Dr Gustvao Cabello’s group shows us the benefits of
of this issue of Periodoncia Clínica. It is a monograph totally immediate loading as an element for maintaining the soft tissues
dedicated to a surgical protocol that over the last 20 years has stable over time. In addition, this issue includes the step-by-step,
generated the biggest debates in the main scientific forums at a long-term results, and drawbacks related to the Socket Shield
global level. This protocol was born in 1976 in Germany when the technique at the hands of the group of Dr Markus Huerzeler and
doctors Schulte and Heimke published the article “The tubinger Dr Otto Zuhr, who invented and presented the technique more
immediate implant”. Published in Quintessenz, a magazine than 10 years ago. As an alternative to a 100% flapless world,
that was only national at that time, it did not achieve sufficient thanks to the group of Prof Massimo de Sanctis, we have learned
visibility, and this only occurred in 1989 when Dr Richard how the key concepts for root coverage can be applied through
Lazzara published the article “Immediate implant placement the technique of the coronally advanced flap combined with
into extraction sites: surgical and restorative advantages” in connective-tissue graft to avoid any dimensional change at the
level of the alveolar crest. Finally, we close with Dr Gary Finelle
International Journal of Periodontics and Restorative Dentistry
who shows us the applications of a protocol for healing abutments
(also known as “la revista bonita” [the beautiful magazine] in
customized for immediate implants in molar zones.
Spain). The protocol gained much visibility and generated much
We can therefore conclude that the available research
curiosity in the world of dentistry by offering the great advantage
indicates that the protocol today is predictable in very specific
of cutting treatment times and invasive surgery for the patient.
clinical situations, offering tangible advantages both for patients
Furthermore, this surgical protocol of immediate implant
and dentists.
placement after the extraction of the tooth also claimed to avoid
Looking to the future, thanks to the brilliant minds of
the physiological resorption that occurs after the extraction of a
researchers and clinicians such as those who have participated in
tooth, and from the decade of the 2000s preclinical and clinical
this monographic issue of Periodoncia Clínica, innovative, daring,
research about this protocol started.
and sometimes transgressive treatments are being designed, but
In fact, after more than 20 years of “scientific method”, always relying on a solid biological base, which establishes the
we have settled many of the biological and clinical concepts new frontiers or “hypotheses” on immediate implants. The future
that we did not know, which has allowed us to tune the surgical challenge which faces us will consist of corroborating these new
technique that has become a standard and predictable protocol. hypotheses to be able to offer, as always, a safe and predictable
We have evolved from a myth to a concrete clinical reality. The treatment to the patients who require it.
title selected for this issue was “New frontiers in immediate Ad mayora semper!
implants”, and it could not be more accurate. In this issue you will
find three reviews on the biological and clinical bases written by
three research groups which have participated first-hand in the
development of the surgical protocol; we are talking about the
research groups of professors Mariano Sanz, Juan Blanco, and Jan
Cosyn. periodonciaclínica 154
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Scientific journal of the

Sociedad Española de Periodoncia

President: National Editorial Committee: Edited by:

Immediate implants in type II alveolar sockets in the aesthetic zone

review articles 101

Biological bases of immediate implants

scientific articles of 139

From myth to a concrete and predictable clinical reality: new

clinical Immediate implants in type II alveolar sockets in the

Paulo Fernando Mesquita de Carvalho.

To Dr Wolney Serio Vieira Filho and Lauro de

Figure 5. Figure 6. Figure 7.

Figures 8, 9 and 10.

Figure 11. Figure 12. Figure 13.

Figures 15, 16 and 17.

Surgical and prosthetic procedure

Figures 18, 19 and 20.

Figure 21. Figures 22 and 23.

Figures 24, 25 and 26.

Figures 33, 34, 35 and 36.

SPECIALIST IN SOFT BONE:

EXPERIENCE THE PROGRESSIVE EFFECT.

Progressive Line Para SEPA - 2.indd 2 13/05/2021 17:58:00

IMMEDIATE DENTOALVEOLAR RESTORATION

José Carlos Martins da Rosa. PhD in Oral

Correspondence to: Conclusion

3. Aim of the treatment

3. Aim of the treatment

Figure 15. Figure 16.

Figure 17. Figure 18.

Figure 19. Figure 20.

Figure 25. Figure 26.

Figure 27. Figure 28. Figure 29.

Figure 30. Figure 31.

CONICAL INTERNAL CONNECTION

Gustavo Cabello. Master’s degree

39 Gustavo Cabello David González Juan Zufía Juan Mesquida

1. Trimodal approach (TA): conventional protocol

Figure 4.2. Figure 4.4.

Figure 4.5. Figure 4.6. Figure 4.7.

Figure 4.8. Figure 4.9. Figure 4.10.

Figure 4.11. Figure 4.12. Figure 4.14.

2. Trimodal approach with modification of the bone department (TAB)

Figure 5.4. Figure 5.3.

Figure 5.5. Figure 5.6. Figure 5.7.

Figure 5.8. Figure 5.9.

Figure 5.10. Figure 5.11.

Figure 6.3. Figure 6.4. Figure 6.5.

Figure 6.6. Figure 6.7. Figure 6.8.

Figure 6.9. Figure 6.10. Figure 6.11.

Figure 6.13. Figure 6.14.

THE PLAUSIBLE. TYPE II ALVEOLI

Nonetheless, recent publications have documented guided bone regeneration

Figure 7.3. Figure 7.2.

Figure 7.4. Figure 7.5. Figure 7.6.

Figure 7.7. Figure 7.8. Figure 7.9.

Figure 7.10. Figure 7.11.

THE IMPONDERABLE. TYPE III ALVEOLI

Figure 8.1. Figure 8.2.

Figure 8.4. Figure 8.5.

Figure 8.6. Figure 8.7.

Figure 8.8. Figure 8.9.

Figure 8.10. Figure 8.11. Figure 8.12.