Correlation between alveolar bone morphology and volumetric dimensional changes in immediate

maxillary implant placement: a 1-year prospective cohort study.

Tiago Borges*, DDS, MSc, PhD, Danilo Fernandes†, DDS, Bruno Almeida‡, DDS, MSc, Miguel

Pereira‡, DDS, MSc, David Martins†, DDS, Luís Azevedo†, DDS, Tiago Marques‡, DDS, MSc

* Assist. Prof, Universidade Católica Portuguesa, Center for Interdisciplinary Research in Health
(CIIS), Institute of Health Sciences (ICS), Viseu, Portugal

† Universidade Católica Portuguesa, Institute of Health Sciences (ICS), Viseu, Portugal

‡ Universidade Católica Portuguesa, Center for Interdisciplinary Research in Health (CIIS), Institute of
Health Sciences (ICS), Viseu, Portugal

Correspondence to:

DDS MSc PhD, Tiago Borges

Universidade Católica Portuguesa

Estrada da Circunvalação

3504-505 Viseu, Portugal

Phone: (00351) 917411447

Fax: (00351) 273328639

Email: geral@cmeb.pt

Word count: 3,669; Figures: 3; Tables: 3; References: 48

Running title: Alveolar changes and immediate implants

Summary: The current study illustrated the influence of the buccal bone plate thickness in the

dimensional changes that affects the peri-implant tissues after immediate maxillary implant

placement procedures. Findings also show the continuous alveolar volume reduction, mainly during

the first month of healing.

This is the author manuscript accepted for publication and has undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1002/JPER.19-0606.

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Authors contribution: All authors have made substancial contributions to conception and design of

the study. TB has been involved in surgical procedures, data collection and dafting the manuscript.

DF has been involved in data collection, data analysis, data interpretation and drafting the

manuscript. BL, MP, DS, LA and TM have been involved in revising the manuscript and have given the

final approval of the version to be published.

ABSTRACT
Background: After a single tooth extraction, remodelling processes are initiated and

morphological changes occur in the alveolar bone. It has been suggested that implant

placement in a fresh extraction socket may parrtly reduce the alveolar ridge contraction and

that several factors like the thickness of the buccal bone wall and the size of the gap between

the implant and the facial bone wall may play a role on peri-implant tissues dimensional

alterations.

Methods: Twenty-six patients treated with single-tooth maxillary implants were included in this

study. A CBCT exam allowed to access the initial buccal bone thickness (BT). Digital impressions

were taken prior to extractions (T0), one month (T1), four months (T2) and 12 months (T3) after

implant insertion and superimposed with a computer software allowing to quantitatively analyse the

three-dimensional changes occurred in the adjacent tissues. Variables related to thickness, area and

volume were computed.

Results: Participants with BT ≤ 1mm exhibited a significantly increased buccal peri-implant tissue

thickness change than patients with BT > 1mm (p = 0.049). At T3 patients representing BT ≤ 1 mm

exhibited a total volume change of -8.53±5.47% compared with patients presenting BT > 1 mm, -

4.37±2.08%. No statistical significance was found on the distance between implant shoulder and the

buccal bone plate (BID) effect.

Conclusion: After the first year of treatment peri-implant tissues showed continuous changes

resulting in a higher thickness and volume reduction at thin buccal bone plates.

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Key Words: dental implants, alveolar ridge augmentation, alveolar bone loss, three-dimensional
imaging, treatment outcome, wound healing.

Introduction

After a single-tooth extraction, the remodelling processes that occur in the alveolar bone have been

proved to take place horizontally, mostly on the buccal aspect of the ridge, followed by the

appearance of a vertical defect.1-4 These outcomes may result in an aesthetic compromise which can

manifest as either a vertical recession in the mid-facial or interdental area, loss of buccal contours in

the horizontal dimension, or differing tissue colour and surface texture.5 These changes to the hard

tissues and surrounding mucosa can be more challenging in the anterior maxilla due to the demand

for satisfactory results.

The literature has suggested that an implant placement in a fresh extraction socket may partly

reduce the alveolar ridge contraction after a tooth extraction,6 but recent clinical evidence shows

that the resorption of the buccal plate will still happen, both vertically and horizontally.7-9 In previous

publications, investigators stated that a careful case selection with intact bone walls, a lingualized

position of the implant, adequate primary stability and the clinician’s expertise need to be

considered as essential parameters to achieve a solid aesthetic outcome with this treatment

modality.10, 11 Several factors have been suggested as affecting the resorption of alveolar bone crest

in immediate implantation including the thickness of the buccal bone wall, the gingival

thickness/biotype, flap or flapless technique, distance from the implant platform to the crestal bone,

surface coating/design, and the size of the gap between the implant and the wall of the alveolar

socket.1, 12, 13 Over the years, strategies have been refined for the reduction of the bone remodelling

and peri-implant mucosal changes in immediate implant insertion in the maxilla. The treatment

modalities described include the placement of autogenous bone to fill the space between the

implant and the buccal bone wall, the placement of deproteinised bovine bone mineral (DBBM) in

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the marginal gap between an immediate implant and the socket walls and the use of a connective

tissue graft.14-16

Although several authors14-16 report that there are some advantages with the use of these

techniques, it is difficult to predict with precision what will happen after immediate implant

placement in the aesthetic zone of the maxilla since it involves hard and soft tissue volume changes.

To understand the behaviour of peri-implant tissues, three-dimensional imaging methods have been

increasingly used to obtain a digital evaluation of the area.16-21 These comparison methods have the

potential to dynamically assess the changes that occur in a pre-defined alveolar area during a

timeline of treatment, as well as correlate them with distinct variables that potentially influence the

treatment outcomes. Initial alveolar bone features like the buccal plate thickness, the size of the gap

between the inner buccal bone cortical and the implant, or the buccal-lingual distance at the fresh

socket area, have been described as influencing peri-implant tissue changes.9, 22, 23
However,

different conclusions can be found in the literature regarding the importance of the bone

morphology as a predictor factor in terms of treatment outcome in maxillary immediate implant

placement.24

The purpose of this investigation is to correlate the initial alveolar bone features with the alveolar

volumetric changes that occur in post-extraction maxillary immediate implant installation in the

aesthetic zone after the first year of treatment.

Material and methods

Study design

The present investigation was designed as a prospective cohort study of implants placed in fresh

post-extraction sites. Twenty-six consecutive patients in need of a single-implant restoration in the

maxillary arch following tooth extraction were enrolled in this study. Patients were treated between

January 2018 and January 2019 at the Dentistry School of the Catholic University of Portugal, Viseu,

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Portugal. The protocol for the present study was reviewed and approved by the Institute of

Bioethics of the Catholic University of Portugal (ERS 10A.2018). All patients included were previously

informed and agreed with written consent to participate in this study in accordance with the 1975

Declaration of Helsinki, revised in 2013. Patients’ inclusion criteria were: 1) ≥18 years of age; 2)

patients who had a failing tooth and needed an implant placing therapy in the aesthetic zone

(between 15-25); 3) the failing tooth has adjacent and opposing natural teeth; 4) sufficient mesial–

distal and inter-occlusal space for placement of the implant and definitive restoration; 5) had an

intact socket wall previously to the extraction; and 6) had sufficient apical bone to place an

immediate implant with a minimum primary stability of 30 N/cm. Exclusion criteria were: individuals

diagnosed with periodontal disease; medical and general contraindications for the surgical

procedure; heavy smokers (> 10 cigarettes/day); and an active infection at the implant site. A

STROBE checklist was performed in order to consider an appropriate guideline for observational

studies.25

Surgical protocol

The surgical procedure was conducted under local anaesthesia 4% articaine

•
UbistesinTM, 3M-ESPE, St. Paul, MN, USA;
*
OsseoSpeed EV™, AstraTech Implant System, Dentsply Implants, Möhndal, Sweden.
# ®
Symbios , Dentsply Implants, Möhndal, Sweden;

** ®
Mucograf Seal , Geistlish Biomaterials, Wolhusen, Switzerland;

 TM
Seralon , Serag-Wiessner, Nalia, Germany;

†
Cerec Omnicam®, Sirona Dental Systems GmbH, Bensheim, Germany;
‡
Ortophos XG 3D®, Sirona Dental Systems GmbH, Bensheim, Germany;

§
PCB 12; Hu-Friedy, Chicago, IL, USA.


Geomagic Control X®, Geomagic, Inc., North Carolina, USA


Materialise Magics®, Materialise, Leuven, Belgium


Materialise Mimics®, Materialise, Leuven, Belgium

¥
SPSS™, Statistical Package for the Social Sciences, version 21.0, IBM Corporation, Armonk, NY, USA

This article is protected by copyright. All rights reserved.

with adrenaline 1:100000•. Flapless tooth extractions were performed after sectioning the tooth,

followed by the use of periotomes and elevators to separate the two parts of the tooth, avoiding

damage to the buccal and palatal bone plates. The socket was inspected to search for any

fenestration or dehiscence of the bone walls, which would have led to exclusion of the patient. All

patients were treated with cylindrical shape implants* with a narrow diameter internal connection

platform following the surgical sequence protocol provided by the manufacturer. The implant was

placed in a correct three-dimensional position, engaging the palatal and apical bone to achieve high

primary stability.26 After implant insertion, a gap of at least 2 mm between the inner cortical buccal

bone plate and the implant surface was filled with a DBBM material# and the socket was sealed with

a resorbable collagen membrane** stabilised with single interrupted 6/0 polyamide sutures. All

surgical procedures were performed by one experienced surgeon (T.B.). The patients had provisional

resin bonded crowns to the adjacent teeth on the same day as the implant surgery; these were in

place for 16 weeks. Postoperative instructions were given to the patients, which included oral

hygiene procedures, chlorhexidine 0.12% rinsing and medication (Paracetamol 1000 mg, ibuprofen

600 mg and amoxicillin 500 mg three times per day for five days). Sutures were removed 10 days

after surgery. A screw-retained provisional crown was delivered after four months of healing and

definitive restorations were inserted at the six-month appointment.

Clinical examination and image acquisition

Examination protocol and data collection consisted of four appointments: 1) T0 (flapless tooth

extraction and implant insertion; 2) T1 (1-month follow-up after implant placement; 3) T2 (4-month

follow-up after implant insertion) and 4) T3 (1-year postoperative follow-up). An intraoral optical

scan† of the upper arch and a CBCT‡ radiographic evaluation were performed followed by tooth

extraction and implant placement (T0). At this point, two clinical parameters were assessed with a

periodontal probe§ to the nearest millimetre: BID (distance between implant shoulder and the

buccal bone plate) and KM (distance between the gingival groove and the mucogingival junction).

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Intraoral scans were completed post-implant placement at one month (T1), four months (T2) and

twelve months (T3). In all follow-up appointments hygiene instructions were given to the patients

and a periodontal care was executed when necessary.

Matching digital models

All digital models were exported from the intraoral optical scan† in STL format and were viewed with

Geomagic Control X. The T0 and T1, T0 and T2, and T0 and T3 STL files were overlapped and a strict

alignment was made into one common coordinate system. A final alignment was done through the

best fit alignment algorithm for a perfect match of digital models and executed with settings

adjusted to the oral cavity.27, 28

Examiner calibration method of digital measurements

A protocol was developed to study the variables of interest in three different computer softwares, ,


. One examiner (D.F), blinded for the surgical procedure, was calibrated by a specialist in the three

software programs used in this study. Calibration was only accepted when 90% of the registers were

within a 0.2 mm difference. Also, an intra-examiner calibration was achieved by Dahlberg d-value

through a double consecutive data collection of 10 randomly chosen patients included in this study.

An intra-class coefficient of 0.91 was obtained.

Linear and volumetric measurements

After the superimposition of digital models, a colour map was created to quantitatively analyse the

three-dimensional changes occurring in the surgical areas and adjacent tissues. Green areas

correspond to the perfect alignment of the model. The variation between yellow and red represents

changes of volumetric increase, whereas the variations between light blue and dark blue represent

the changes of volumetric decrease. A region of interest (ROI) with 10 section planes, perpendicular

to the coronal section of the tooth, was computed at buccal and palatal aspect (Figure 1). These

sections were set at the most apical point of the gingival margin and ended 5 mm above it. Mesially

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and distally, a line passing through the interproximal area limited the region of interest. The same

ROI was used in each patient, at the different comparison points. The intersection of these sections

with the overlapping models allowed the linear changes to be obtained in each area. The Mean

Buccal Change (MBC0-1, MBC0-2, and MBC0-3) and Mean Total Change (MTC0-1, MTC0-2 and MTC0-3)

were calculated in millimetres (mm) to evaluate the changes that occurred in peri-implant contour

(Figure 2).

Digital models were superimposed in a computer software, and then exported to a different

computer software for volumetric assessement. A volumetric ROI was manually selected with “Cut

or Punch” function using interproximal areas as mesial and distal limits. All cuts were performed in

the same way in all digital models so that all measurements were carried out in the same areas. ROI

volume at T0 was computed for further comparison with consecutive volume change values (Figure

3). The 3D-analysis was conducted with “Boolean” functions, which allowed researchers to obtain

the volume change in each time point from different variables like the Buccal Volume Change (BVC0-1,

BVC0-2, and BVC0-3) and Total Volume Change (TVC0-1, TVC0-2, e TVC0-3), computed in cubic millimetres

(mm3). To allow a direct comparison of different sites at different time points, relative percentages

of these variables were calculated based on the ROI volume at T0.20 All measurements were

recorded to the nearest 0.01 mm.

Radiographic assessment

The acquisition of radiographic images was performed with a volumetric dimension of 8 x 8 cm for

14s with the XG 3D tomography acquisition protocol, with a voxel size of 0.1 mm in HD mode. The

CBCT images were imported in a DICOM format to a computer software to perform the

measurements. Buccal plate thickness (BT) was assessed for 3D radiographic analysis to evaluate the

initial features of the alveolar bone. All measurements were obtained through coronal slice

reconstructions, using an adjacent line to the sinus/nasal plate as a reference. BT was measured 1

mm above the coronal bone margin using a central slice, as well at the mesial and distal slices,

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ranging 1 mm from the central slice. Mean BT values were obtained as the average values of the

three slices. One independent examiner who was not involved in the study executed all

measurements.

Statistical analysis

The outcome variables were presented as mean values, standard deviation and 95% confidence

interval. Measurement time (T1, T2 and T3) was considered as a factor and the following as

covariates: age, gender, KM height, location, implant length, BID and BT. The statistical analysis was

performed using a computer software¥. The Mann–Whitney U-test was used to disclose differences

for continuous non-paired variables. Moreover, the paired Wilcoxon test was used when the normal

distribution of the groups was proved. A multiple linear regression model, using the stepwise

forward method, was built to analyse the effect of the tested treatment in the main outcome

variables throughout the study. All hypothesis tests were conducted at the 5% level of significance.

Results

Patients and implants

Details regarding patient characteristics at baseline are shown in Table 1. Twenty-six patients with a

mean age of 53.04 +/- 12.11 (range from 34 to 85) who had been treated with 26 single-tooth

immediate implants were examined. In all, 46.15% of the patients (n=12) were males and 53.85%

were females (n=14). No biological complications occurred in any included patients or implant sites

during the follow-up period. No technical complications were recorded during the 12-month follow-

up. Sample size and power calculation were computed taking into consideration a significance value

of α = 0.05 (type I error) and the power at β = 5.09% (type II error) obtaining a sample size power of

94,9%.

Radiographic measurements

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A CBCT analysis allowed computing the BT values through the three measurements from three

adjacent slices. This variable showed a mean value of 1.02±0.62 mm (ranging from 0.10 to 2.53). The

vast majority of the buccal bone walls (57.7%) presented a BT ≤ 1 mm, whereas 42.3% exhibited a BT

> 1 mm.

Linear and volumetric changes over time

Linear and volumetric changes in BT ≤ 1 mm and BT > 1 mm classes are presented in Table 2. The

linear measurements showed a buccal mean change in thickness at 1-year follow-up of -

0.48±0.28mm when BT ≤ 1 mm and -0.17±0.11mm when BT > 1 mm (p = 0.049). Although mean

total change only revealed significant statistical results at T2 (p = 0.015), after one year of treatment

it was observed a change of -0.59±0.40mm in BT ≤ 1 mm class compared with -0.31±0.12mm

observed when BT > 1 mm, demonstrating almost a two times bigger difference between each

group.

Regarding the volumetric analysis, patients representing BT > 1 mm exhibited again better results

than patients with BT ≤ 1 mm, presenting a significant different BVC (%) at T1 (p = 0.018), BVC (%)

(p = 0.010) and TVC (%) at T2 (p = 0.012) (see Supplementary Figure 1 in online Journal of

Periodontology). At the one-year follow-up appointment, buccal volume change was -11.27 ± 7.72

% when BT ≤ 1 mm compared with the observed -4.27 ± 3.39 %, when BT > 1 mm.

Regarding BID values, less changes could be found when BID > 2 mm. At 1-year follow-up it was

observed a total volume change of -10.88±6.59% when BID ≤ 2 mm and when BID > 2 mm, -

5.80±3.54%. Nevertheless, BID values showed no significant difference on thickness and volume

change of the peri-implant tissue contour over one, four and twelve months of observation (see

Supplementary Table 1 in online Journal of Periodontology).

Correlations

A multi-variate regression analysis was conducted to evaluate BT and BID effect on buccal peri-

implant tissue thickness and volume changes (Table 3). Although no significant influence of BID on

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MBC and BVC at T1 or T3 were found, this analysis proved a statistical significant influence of BT on

buccal peri-implant tissue thickness and volume changes over time. BT values influenced MBC after

1 year of treatment (p = 0.016) and BVC at T1 (p = 0.015) and T3 (p = 0.009), respectively.

Discussion
This investigation comprised a prospective cohort study of 26 dental implants, placed in the

maxillary arch immediately after tooth extraction. To minimise the impact that the surgeon’s skills

might have had in the final aesthetic result, all surgical procedures were carried out by an

experienced implant surgeon (T.B.) and patients were only included in the study group if they

received a dental implant with no associated defects of the alveolar bone walls. Implant placement

in fresh extraction sockets has been widely discussed and several studies show consistent favourable

results. Lops et al.29 addressed a prospective analysis of 46 post-extraction single implant

placements and clinical outcomes showed a 100% success rate. A growing number of studies confirm

these findings with post-extraction implant survival rates as predictable as in healed bone, even

when different implant morphologies are used.30-33 We also accept that the high predictability of

osseointegration is achieved when a specific set of selection criteria is applied, and a strict surgical

and restorative protocol is observed. In fact, the period from the surgical stage to the final

restoration step represents a critical time lapse for the tissue healing and the restoration option.34-36

Some literature reveals heterogeneity in the parameters used to evaluate the aesthetic outcomes of

an implant restoration.5, 37, 38 A great number of the indexes utilised to assess the results of implant

treatments in aesthetic areas are observer-dependent and reveal moderate reproducibility between

observers.39 The digital evaluation methods used in our investigation intend to provide an objective

and quantitative analysis of the peri-implant tissue evolution after immediate implant insertion, as

well as establish a possible correlation between the initial alveolar bone features and the alveolar

healing progression. The same ROI was used in each patient to compare thickness changes in a

uniform way. Also, since all ROI were different from each patient due to anatomical variations,

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relative percentages of the areas and volumes were calculated to allow a direct comparison between

the different sites.40

Distinct variables have been described as factors that might influence the hard tissue dimensional

alterations following tooth extraction in the maxillary region. Ferrus et al.9 defined the location of

the implant, the thickness of the buccal bone crest, the extraction motive or the dimension of the

horizontal bone gap as predictable variables that potentially have an effect on peri-implant bone

resorption in fresh extraction sockets. Studies showed the outcomes of the hard-tissue graft, mainly

a bone substitute that was placed in the space between the implant surface and the inner surface of

the buccal bone wall.41, 42

The findings from these reports demonstrate that graft procedures,

combined with implant placement, may counteract ridge alterations following tooth extraction.

Similar findings had already been outlined by Araújo et al.43 in a study about socket preservation

procedures. According to the authors, the healing ridge contraction in fresh sockets filled with

bovine xenograft can be less conspicuous, not only for the buccal bone wall properties but also for

the four-wall defect-containing capacity, which may be more effective at incorporating the graft

material. All the sockets of our sample were grafted with DBBM, which filled the gap between the

inner buccal bone wall and the implant surface.

Januario et al.44 described the morphological features of the alveolar process in the anterior maxilla

(canine to canine) in humans, measuring the thickness of the buccal bone plate at three different

positions in relation to the buccal bone crest. Cone-beam computer tomograms were obtained from

this area showing that the buccal bone plate in most locations is ≤ 1 mm and up to 50% of the sites

had a bone plate of ≤ 0.5 mm. In the present study, almost half (N=11) of the consecutively included

patients had a buccal bone plate with a thickness of > 1 mm, which could be explained by the

inclusion of premolars in digital analysis.45

Almost no clinical studies have been found in the literature comparing the initial alveolar bone

morphology and the immediate implant installation outcomes in the aesthetic maxillary areas. To

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test the influence that the buccal plate thickness may have in the healing process of the immediate

implant socket alteration, Arora et al.24 studied the possible correlation between preoperative

buccal cortical bone thickness and peri-implant tissue response following immediate implant

placement. The 18 patients with intact socket walls underwent a treatment strategy that involved a

flapless extraction procedure, implant placement and grafting of the implant-socket gap with a

xenograft material. The authors compared the preoperative bone width with the soft tissue and

aesthetic outcomes obtained by a Pink Esthetic Score, after a two-year follow-up period, and found

no significant correlation between both variables. These results are not in accordance with those

obtained from our investigation since the preoperative buccal cortical bone thickness proved to

influence the dimensional change that affects the peri-implant tissues after immediate implant

placement procedures (Table 2). Our data suggest that after one year of treatment, when BT ≤ 1 mm

we can expect a significant buccal tissue horizontal retraction compared with the implant sites that

presented BT > 1 mm (p = 0.049). The difference can be noticed by the diverse negative evolution of

the buccal section at the two BT classes at the 12-month follow-up (MBC T0 –T3 -0.48 ± 0.28 mm and

MBC T0 –T3 -0.17 ± 0.11 mm, when BT ≤ 1 and BT > 1 mm, respectively). In fact, it is clear that

individuals diagnosed with a thinner buccal bone plate undergo a marked reduction of the alveolar

tissues, from the first month of treatment. These findings are comparable with the results of Tomasi

et al.40, which point toward significantly higher alveolar volume reduction at sites with a thin buccal

bone wall (≤ 1 mm), a the 6-month evaluation.

It must be outlined that in the present investigation no separation was made in terms of soft tissue

and bone evaluation during the healing period, resulting in a lack of information towards the effect

of the grafting procedure in the hard tissues. Because of this, we can speculate that some of the

volumetric outcomes of the alveolar ridge might be due to compensatory variations of the mucosa,

has suggested by Chappuis et al.46

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Despite of this, our study results are in accordance with several authors that emphatize the

importance of the thin labial bone plate as a predictor factor for higher rates of mucosal recession

and bone resorption around immediate implants inserted at the esthetic maxillary area.47 Also, we

must highlight the importance of a long-term follow-up of this treatment modality. Cosyn et al.,

concluded that after the 1-year evaluation, and despite the favourable early results obtained by

immediate maxillary implants in terms of survival rate and MBL, mid-facial recession and mid-facial

contour deterioration could be noticed48.

The appraisal beween different treatment options that potencially minimize the contraction of the

facial tissues, like the use of connective tissue grafts, or the comparison between different implant

insertion aproaches (immediate vs delayed) should be considered for future studies.

Conclusion
After the first year of treatment following single immediate implant placement in the maxilla, peri-

implant tissues showed a continuous alteration resulting in a thickness change that occurred mainly

in the first month and tended to be stable after the fourth month of follow-up. Linear section and

alveolar volume changes were significantly influenced by the buccal bone plate thickness.

Acknowledgments

The authors thank Dr. Celeste Morais, Professor of Statistics, for the support with the statistical

analysis.

Conflict of interest

The authors declare no conflict of interest in relation to this manuscript.

References

1. Araújo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An

experimental study in the dog. J Clin Periodontol 2005;32:212-218.

This article is protected by copyright. All rights reserved.

2. Chappuis V, Engel O, Reiyes M, Shahim K, Nolte LP, Buser D. Ridge alterations post-extraction

in the esthetic zone: a 3D analysis with CBCT. J Dent Res 2013;92:195S-201S.

3. Lekovic V, Camargo PP, Klokkevold P, et al. Preservation of alveolar bone in extraction

sockets using bioabsorbable membranes. J Periodontol 1998;69:1044-1049.

4. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes

following single-tooth extraction: a clinical and radiographic 12-months prospective study. Int J

Periodontics Restorative Dent 2003;23:313-323.

5. Fϋrhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. Evaluation of soft tissue

around single-tooth implant crowns: the pink esthetic score. Clin Oral Implants Res 2005;16:639-444.

6. Watzek G, Haider R, Mensdorff-Pouilly N, Haas R. Immediate and delayed implantation for

complete restoration of the jaw following extraction of all residual teeth: a retrospective study

comparing different types of serial immediate implantation. Int J Oral Maxillofac Implants

1995;10:561–567.

7. Arora H, Khzam N, Roberts D, Bruce WL, Ivanovski S. Immediate implant placement and

restoration in the anterior maxilla: Tissue dimensional changesafter 2-5 year follow up. Clin Implant

Dent Relat Res 2017;19:694-702.

8. Sanz M, Cecchinato S, Ferrus J, Pjertursson EB, Lang NP, Lindhe J. A prospective, randomized-

controlled clinical trial to evaluate bone preservation using implants with differente geometry placed

into extractio sockets in the maxilla. Clin Oral Implants Res 2010;21:13-21.

9. Ferrus J, Cecchinato D, Pjetursson EB, Lang NP, Sanz M, Lindhe J. Factors influencing ridge

alterations following immediate implant placement into extraction sockets. Clin Oral Implants Res

2010;21:22–29.

10. Lang NP, Pun L, Lau KY, Li KY, Wrong MC. A systematic review on survival and success rates

This article is protected by copyright. All rights reserved.

of implants placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Implants

Res 2012;23:39-66.

11. Chen ST, Buser, D. Esthetic outcomes following immediate and early implant placement in

the anterior maxilla - a systematic review. Int J Oral Maxillofac implants 2014;29 Suppl:186–215.

12. Botticelli D, Persson LG, Lindhe J, Berglundh T. Bone tissue formation adjacent to implants

placed in fresh extraction sockets: An experimental study in dogs. Clin Oral Implants Res

2006;17:351–358.

13. Januário AL, Barriviera M, Duarte WR. Soft tissue cone-beam computed tomography: a novel

method for the measurement of gingival tissue and the dimensions of the dentogingival unit. J

Esthet Restor Dent 2008;20:366–373.

14. Becker W, Becker BE, Polizzi G, Bergstrom C. Autogenous bone grafting of bone defects

adjacent to implants placed into immediate extraction sockets in patients: a prospective study. Int J

Oral Maxillofac Implants 1994;9:389–396.

15. Sanz M, Lindhe J, Alcaraz J, Sanz-Sanchez I, Cecchinato D. The effect of placing a bone

replacement graft in the gap at immediately placed implants: a randomized clinical trial. Clin Oral

Implants Res 2017;28:902–910.

16. Poskevicius L, Sidlauskas A, Galindo-Moreno P, Juodzbalys, G. Dimensional soft tissue

changes following soft tissue grafting in conjunction with implant placement or around present

dental implants: a systematic review. Clin Oral Implants Res 2017;28:1–8.

17. Bienz SP, Jung RE, Sapata VM, Hämmerle CHF, Hüsler J, Thoma DS. Volumetric changes and

peri-implant health at implant sites with or without soft tissue grafting in the esthetic zone, a

retrospective case-control study with a 5-year follow-up. Clin Oral Implants Res 2017;28:1459–1465.

18. Sanz Martin I, Benic GI, Hämmerle CH, Thoma DS. Prospective randomized controlled clinical

This article is protected by copyright. All rights reserved.

study comparing two dental implant types: volumetric soft tissue changes at 1 year of loading. Clin

Oral Implants Res 2016;27:406–411.

19. Schneider D, Grunder U, Ender A, Hämmerle CH, Jung RE. Volume gain and stability of peri-

implant tissue following bone and soft tissue augmentation: 1-year results from a prospective cohort

study. Clin Oral Implants Res 2011;22:28–37.

20. Szathvary I, Caneva M, Bressen E, Botticelli D, Meneghello R. A volumetric 3-D digital analysis

of dimensional changes to the alveolar process at implants placed immediately into extraction

sockets. J Oral Sci Rehab 2015;1:62–69.

21. van Nimwegen WG, Goené RJ, Van Daelen AC, Stellingsma K, Raghoebar GM, Meijer HJ.

Immediate placement and provisionalization of implants in the aesthetic zone with or without a

connective tissue graft: a 1-year randomized controlled trial and volumetric study. Clin Oral Implants

Res 2018;29:671–678.

22. Tomasi C, Sanz M, Cecchinato D, Pjetursson B, Ferrus J, Lang NP, Lindhe J. Bone dimensional

variations at implants placed in fresh extraction sockets: a multilevel multivariate analysis. Clin Oral

Implants Res 2010;21:30-36.

23. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone thickness on facial marginal

bone response: stage 1 placement through stage 2 uncovering. Ann Periodontol 2000;5:119–128.

24. Arora H, Ivanovski S. Correlation between pre-operative buccal bone thickness and soft

tissue changes around immediately placed and restored implants in the maxillary anterior region: a

2-year prospective study. Clin Oral Implants Res 2017;29:346–352.

25. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement:

guidelines for reporting observational studies. J Clin Epidemiol 2008;6:344-349.

This article is protected by copyright. All rights reserved.

26. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior

maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004;19 Suppl:43-61.

27. Emir F, Piskin B, Sipahi C. Effect of dental technician disparities on the 3-dimensional

accuracy of definitive casts. J Prosthet Dent 2017;117: 410–418.

28. Nedelcu R, Olsson P, Nyström I, Rydén J, Thor A. Accuracy and precision of 3 intraoral

scanners and accuracy of conventional impressions: a novel in vivo analysis method. J Dent

2018;69:110–118.

29. Lops D, Chiapasco M, Rossi A, Bressan E, Romeo E. Incidence of inter-proximal papilla

between a tooth and an adjacent immediate implant placed into a fresh extraction socket: 1-year

prospective study. Clin Oral Implants Res 2008;19:1135-1140.

30. Cosyn J, Eghbali A, Hanselaer L, et al. Four modalities of single implant treatment in the

anterior maxilla: a clinical, radiographic, and aesthetic evaluation. Clin Implant Dent Relat Res

2013:15:517-530.

31. Noelken R, Kunkel M, Jung BA, Wagner W. Immediate nonfunctional loading of NobelPerfect

implants in the anterior dental arch in private practice – 5-year data. Clin Implant Dent Relat Res

2014;16:21-31.

32. Sanz M, Cecchinato D, Ferrus J, et al. Implants placed in fresh extraction sockets in the

maxilla: clinical and radiographic outcomes from a 3-year follow-up examination. Clin Oral Implants

Res 2014;25:321-327.

33. Cosyn J, De Lat L, Seyssens L, Doornewaard R, Deschepper E, Vervaeke S. The

effectiveness of immediate implant placement for single tooth replacement compared to delayed

implant placement: A systematic review and meta-analysis. J Clin Periodontol 2019;46 Suppl

21:224-241.

This article is protected by copyright. All rights reserved.

34. Borges T, Lima T, Carvalho À, Dourado C, Carvalho V. The influence of customized abutments

and custom metal abutments on the presence of the interproximal papilla at implants inserted in

single-unit gaps: a 1-year prospective clinical study. Clin Oral Implants Res 2014;25:1222-1227.

35. de Rouck T, Collys K, Cosyn J. Single-tooth replacement in the anterior maxilla by means of

immediate implantation and provisionalization: a review. Int J Oral Maxillofac Implants 2008;23:897-

904.

36. den Hartog L, Raghoebar GM, Stellingsma K, Vissink A, Meijer HJ. Immediate non-occlusal

loading of single implants in the aesthetic zone: a randomized clinical trial. J Clin Periodontol

2011;38:186-194.

37. Meijer HJA, Stellingsma K, Meijndert L, Raghoebar GM. A new index for rating aesthetics of

implant - supported single crowns and adjacent soft tissues – The Implant Crown Aesthetic Index.

Clin Oral Implants Res 2005;16:645-649.

38. Belser UC, Grütter L, Vailati F, Bornstein MM, Weber HP, Buser D. Outcome evaluation of

early placed maxillary anterior single-tooth implants using objective esthetic criteria: a cross-

sectional, retrospective study in 45 patients with a 2- to 4-year follow-up using pink and

white esthetic scores. J Periodontol 2011;72:1364-1371.

39. Hof M, Umar N, Budas N, Seemann R, Pommer B, Zechner W. Evaluation of implant esthetics

using eight objective indices-Comparative analysis of reliability and validity. Clin Oral Implants

Res 2018;29:697-706.

40. Tomasi C, Regidor E, Ortiz-Vigón A, Derks J. Efficacy of reconstructive surgical therapy at

peri-implantitis-related bone defects. A systematic review and meta-analysis. J Clin Periodontol

2019;46 Suppl 21:340-356.

41. Caneva M, Botticelli D, Morelli F, Cesaretti G, Beolchini M, Lang NP. Alveolar process

This article is protected by copyright. All rights reserved.

preservation at implants installed immediately into extraction sockets using desproteinized bovine

bone mineral – an experimental study in dogs. Clin Oral Implants Res 2012;23:789-796.

42. Caneva M, Botticelli D, Pantani F, Baffone GM, Rangel IG Jr, Lang NP. Deproteinized bovine

bone mineral in marginal defects at implants installed immediately into extraction sockets: an

experimental study in dogs. Clin Oral Implants Res 2012;23:106-112.

43. Araújo MG, da Silva JCC, de Mendonça AF, Lindhe J. Ridge alterations following grafting of

fresh extraction sockets in man. A randomized clinical trial. Clin Oral Implants Res 2015;26:407-412.

44. Januário AL, Duarte WR, Barriviera M, Mesti JC, Araújo MG, Lindhe J. Dimensional of the

facial bone wall in the anterior maxilla: a cone-beam computed tomography study. Clin Oral

Implants Res 2011;22:1168-1171.

45. Huynh-Ba G, Pjetursson BE, Sanz M, Cecchinato D, Ferrus J, Lindhe J, Lang NP. Analysis of

thee socket bone wall dimensions in the upper maxilla in relation to immediate implant placement.

Clin Oral Implants Res 2010;21:37-42.

46. Chappuis V, Engel O, Shahim K, Reyes M, Katsaros C, Buser D. Soft tissue alterations in

esthetic postextraction sites: A 3-dimensional analysis. J Dent Res 2015;94;187S-193S.

47. Yang X, Zhou T, Zhou N, Man Y. The thickness of labial bone affects the esthetics of

immediate implant placement and provisionalization in the esthetic zone: A prospective cohort

study. Clin Implant Dent Relat Res 2019;21:482-491.

48. Cosyn J, Eghbali A, Hermans A, Vervaeke S, De Bruyn H, Cleymaet R. A 5-year prospective

study on single immediate implants in the aesthetic zone. J Clin Periodontol 2016;43:702-709.

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Figure 1. Determination of the region of interest (ROI) in superimposed models.

Figure 2. Buccal and palatal linear alterations.

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Figure 3. Selection of the ROI for volumetric evaluation; A: Buccal ROI; B: Palatal ROI; C: Buccal and

palatal ROI; D: Volumetric ROI for total alveolar volume assessment.

Table 1: Characterization of study sample in age, gender, implant site and dimension, BID and KM.

Patient N=26 (100.0%)

Age Mean SD Minimum Maximum

Male 58.18 12.49 37 85

Female 49.27 10.71 34 76

Total 53.04 12.11 34 85

Gender (N) (%)

Male 12 46.15

Female 14 53.85

Total 26 100.0

Implant site (N) (%)

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 Central incisor 5 19.23

Lateral incisor 5 19.23

First PM 12 46.15

Second PM 4 15.38

Total 26 100.0

Implant (N) (%)

EV 4.2x11 mm 6 23.08

EV 3.6 x 9 mm 1 3.85

EV 3.6x11 mm 18 69.23

EV 3.6x13 mm 1 3.85

Total 26 100.0

Intra-operative
Mean SD Minimum Maximum
measurements

BID 3.08 0.93 2 5

KM 3.88 1.21 2 6

Table 2: Alveolar tissue change from baseline to 1-year in relation with the buccal plate thickness.

Minimum;M CI(95%)
Variable N BT Mean SD P-value
aximum Lower;Upper

MBC T0-T1 15 ≤1mm -1.15;0.20 -0.32 0.37 -0.53;-0.12

0,061
(mm) 11 >1mm -0.44;0.19 -0.11 0.17 0.22;0.00

MBC T0-T2 15 ≤1mm -1.03;0.13 -0.46 0.37 -0-72;-0.21

0,017*
(mm) 11 >1mm -0.32;0.06 -0.14 0.10 -0.21;-0.70

MBC T0-T3 15 ≤1mm -0.97;-0.06 -0.48 0.28 -0.67;-0.28

0.049*
(mm) 11 >1mm -0.30;-0.04 -0.17 0.11 -0.35;0.01

MTC T0-T1 15 ≤1mm -1.62;0.10 -0.66 0.59 -1.05;-0.26

0.065
(mm) 11 >1mm -0.99;0.16 -0.25 0.34 -0.47;-0.01

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 MTC T0-T2 15 ≤1mm -1.37;-0.01 -0.65 0.47 -0.97;-0.34
0.015*
(mm) 11 >1mm -0.49;-0.11 -0.26 0.12 -0.34;-0.18

MTC T0-T3 15 ≤1mm -1.30;-0.06 -0.59 0.40 -0.92;-0.34

0.066
(mm) 11 >1mm -0.55;0.09 -0.31 0.22 -0.60;0.07

15 ≤1mm -53.32;9.73 -27.45 18.53 -39.22;-15.67

BVC T0-T1 (mm3) 0.012*
11 >1mm -34.29;7.81 -10.07 10.28 -16.97;-3.16

15 ≤1mm -70.07;7.05 -30.57 21.14 -44.78;-16.37

BVC T0-T2 (mm3) 0.012*
11 >1mm -30.42;3.42 -10.44 8.33 -16.04;-4.85

15 ≤1mm -69.26;7.05 -29.06 21.25 -43.45;-14.79

BVC T0-T3 (mm3) 0.219
11 >1mm -24.09;-3.29 -11.89 10.86 -25.49;3.03

15 ≤1mm -98.00;2.93 -46.53 32.51 -68.37;-24.70

TVC T0-T1 (mm3) 0.045*
11 >1mm -76.97;6.03 -20.90 22.74 -36.18;-5.63

15 ≤1mm -95.49;-7.37 -45.82 28.91 -65.24;-26.40

TVC T0-T2 (mm3) 0.017*
11 >1mm -52.05;-9.44 -21.30 11.69 -29.15;-13.45

15 ≤1mm -96.34;-16.12 -40.32 26.48 -58.11;-22.38

TVC T0-T3 (mm3) 0.302
11 >1mm -37.96;-11.80 -22.59 13.67 -40.43;3.23

BVC T0-T1 15 ≤1mm -19.16;3.53 -10.22 7.31 -14.86;-5.58

0.018*
(%) 11 >1mm -11.20;3.05 -3.91 3.84 -6.49;-1.33

BVC T0-T2 15 ≤1mm -25.68;2.56 -11.57 7.67 -16.72;-6.41

0.010*
(%) 11 >1mm -9.94;1.34 -4.08 3.03 -6.11;-2.05

BVC T0-T3 15 ≤1mm -25.38;2.56 -11.27 7.72 -16.83;-6.33

0.168
(%) 11 >1mm -7.87;-1.14 -4.27 3.39 -8.45;0.94

TVC T0-T1 15 ≤1mm -16.11;0.51 -8.39 6.02 -12.44;-4.35

0.088
(%) 11 >1mm -13.19;0.85 -4.42 4.22 -7.26;-1.59

TVC T0-T2 15 ≤1mm -20.15;-1.38 -9.24 5.40 -12.87;-5.61

0.012*
(%) 11 >1mm -8.92;-2.07 -4.42 2.06 -5.80;-3.04

TVC T0-T3 15 ≤1mm -20.33;-3.14 -8.53 5.47 -12.52;-5.05

0.239
(%) 11 >1mm -6.50;-2.35 -4.37 2.08 -7.35;0.32

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MBC, Mean Buccal Change (mm); MTC, Mean Total Change (mm); BVC, Buccal Volume change (mm3/%); TVC, Total Volume
change (mm/%3); BT, Buccal bone thickness (mm); SD, Standard deviation; * statistically significant changes at the 5% level;
Ci, Confidence interval

Table 3: Multivariate regression analysis

2 F Statistical Standardized t Statistical (P-

Variable Regressors Adjusted R
(P) Coefficients value)

Constant -0.165 -0.539(0.038)

MBC T0-T1 2.622
BT 0.163 0.348 1.879 (0.071)
(mm) (0.076)
BID -0.013 -0.072 (0.361)

Constant -0.654* -2.138(0.046)

MBC T0-T3 3.928
BT 0.295 0.497* 2.663 (0.016*)
(mm) (0.026)
BID 0.175 0.938 (0.361)

Constant -12.533 -1.846(0.080)

BVC T0-T1 4.241
BT 0.306 0.477* 2.681 (0.015*)
(%) (0.019)
BID 0.159 0.891 (0.384)

Constant -15.561* -2.542(0.020)

BVC T0-T3 4.701
BT 0.346 0.526* 2.926 (0.009*)
(%) (0.014)
BID 0.173 0.960 (0.350)

MBC, Mean Buccal Change (mm); BVC, Buccal Volume change (%); * statistically significant changes at the 5% level.

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