GOOD MORNING

SURGICAL TECHNIQUES AND

PROTOCOLS FOR IMMEDIATE
IMPLANT PLACEMENT VS
DELAYED IMPLANT
PLACEMENT
PRESENTED BY: Dr. Yashika Kalyani
1st year post graduate
Dept of periodontics
CONTENTS

 Introduction
 Timing of Implant Placement
 General Principles of Implant Surgery
 Delayed implant placement
 Healing in delayed implant placement
 Literature review
 Immediate implant placement
 Outcome and advantages of immediate implant placement
 Criteria for immediate implant placement
 Surgical technique
 Healing in immediate implant placement
 Literature review
 Immediate v/s delayed implant placement
 Conclusion
INTRODUCTION

 The surgical procedures for the placement of nearly all endosseous dental implants currently used are based
on the original work of Professor Per-Ingvar Brånemark and colleagues in Sweden in the 1960s and 1970s.
 The same fundamental principles of atraumatic, precise implant site preparation applies to all implant
systems.
 Briefly, this includes a gentle surgical technique and progressive, incremental preparation of the bone for a
precise fit of the implant at the time of placement.
 TIMING OF IMPLANT PLACEMENT

Chen, Stephen & Buser, Daniel. (2009). Clinical and esthetic outcomes of implants placed in postextraction sites. Int J Oral
Maxillofac Implants; 24 Suppl: 186-217.
Clinical periodontology and implant dentistry, Jan Lindhe, 6 th edition
GENERAL PRINCIPLES OF IMPLANT
SURGERY

Patient Preparation

 Most implant surgical procedures can be done in the office using local anesthesia.
 Conscious sedation (oral or intravenous) may be indicated for some patients.
 The risks and benefits of implant surgery specific to the patient's situation and needs should be thoroughly
explained prior to surgery.
 A written, informed consent should be obtained for the procedure.
Implant Site Preparation

 Some basic principles must be followed to achieve osseointegration with a high degree of predictability.
 The surgical site should be kept aseptic, and the patient should be appropriately prepared and draped for an
intraoral surgical procedure.
 Prerinsing with chlorhexidine gluconate for 1 to 2 minutes immediately before the procedure will aid in
reducing the bacterial load present around the surgical site.
 Every effort should be made to maintain a sterile surgical field and to avoid contamination of the implant
surface.
 Implant sites should be prepared using gentle, atraumatic surgical techniques with an effort to avoid
overheating the bone.
Basic Principles of Implant Therapy to Achieve Osseointegration
1. Implants must be sterile and made of a biocompatible material (e.g., titanium).
2. Implant site should be prepared under sterile conditions.
3. Implant site should be prepared with an atraumatic surgical technique that avoids overheating of the bone
during preparation of the recipient site.
4. Implants should be placed with good initial stability.
5. Implants should be allowed to heal without loading or micromovement (i.e., undisturbed healing period to
allow for osseointegration) for 2 to 4 or 4 to 6 months, depending on the bone density, bone maturation, and
implant stability.
DELAYED IMPLANT PLACEMENT

 Delayed implant placement is defined as the placement of an implant into the post extraction socket after a
substantial healing of the socket.
 Placed at least 2 months after the tooth extraction.
 Although there are many advantages to immediate implant placement, it is not always possible to treat tooth
loss right away.
 Since the primary goal of implant treatment is to ensure it will be a success, it is important to consider when
delayed implant placement may be the better option for patients.
INDICATIONS:

 In adolescent patients who are too young for implant placement and when extraction of the tooth
cannot be delayed.
 Presence of extensive bone lesion in periapical area.
 When an infection or other dental complications are present.
 When the patient has experienced jawbone degeneration at the site of tooth loss.
 When a molar or premolar has been lost (these teeth have larger roots, and data suggests immediate
implant placement may not be the best option for these teeth).
DISADVANTAGES:

 Volume loss of alveolar bone.

 Increased time of edentulism.
 Longer treatment time.
 Additional surgical procedure.
 Psychological impact on the patient .
Implant site preparation (osteotomy) for a 4- mm diameter, 10-mm length screw-type, threaded (external hex)
implant in a subcrestal position.
FLAP DESIGN, INCISIONS, AND ELEVATION

 Flap management for implant surgery varies slightly, depending on the

location and objective of the planned surgery.
 There are different incision/flap designs, but the most common is the
crestal flap design.
 The incision is made along the crest of the ridge, bisecting the existing
zone of keratinized mucosa.
 The crestal incision, however, is preferred in most cases, because
closure is easier to manage and typically results in less bleeding, less
edema, and faster healing.
 A full-thickness flap is raised (buccal and lingual) up to or slightly
beyond the level of the mucogingival junction, exposing the alveolar
ridge of the implant surgical sites.
 The bone at the implant site must be thoroughly debrided of all
granulation tissue.
 For a “knife-edge” alveolar process with sufficient alveolar bone
height and distance from vital structures (e.g., inferior alveolar nerve),
a large round bur is used to recontour or flatten the bone to provide a
wider, level surface for the implant site preparation.
 However, if the vertical height of the alveolar bone is limited (e.g.,
<10 mm), the knife-edge alveolar bone height should be preserved.
IMPLANT SITE PREPARATION

 Once the flaps are reflected and the bone is prepared (i.e., all
granulation tissue removed and knife-edge ridges flattened), the
implant osteotomy site can be prepared.
 A series of drills are used to prepare the osteotomy site precisely
and incrementally for an implant.
 A surgical guide or stent is inserted, checked for proper
positioning, and used throughout the procedure to direct the
proper implant placement.
It is important to use the surgical stent to determine the mesial-distal
and buccal-lingual dimensions and proper angulation of the implant
placement.

Frequent use of the guide pins ensures parallelism of

the implant placement.
Round Bur

 A small round bur (or spiral drill) is used to make the initial penetration into bone for the
implant site.
 The surgical guide is removed, and the initial marks are checked.
 Slight modifications may be necessary to adjust spatial relationships and to avoid minor ridge
defects.
 Any changes should be compared with the prosthetically driven surgical guide positions.
 Each marked site is then prepared to a depth of 1 to 2 mm with a round drill, breaking through
the cortical bone and creating a starting point for the 2-mm twist drill.
The 2-mm Twist Drill

 A small twist drill, usually 2 mm in diameter and marked to indicate various lengths, is used
next to establish the depth and align the long axis of the implant recipient site .
 This drill may be externally or internally irrigated. In either case, the twist drill is used at a
speed of approximately 800 to 1500 rpm, with copious irrigation to prevent overheating of the
bone.
 Clinicians should pump the drill (up and down) intermittently and avoid using a constant “push”
of the drill in the apical direction only.
 The relationship to neighboring vital structures (e.g., nerve and tooth roots) can be determined by taking a
periapical radiograph with a guide pin or radiographic marker in the osteotomy site.
 Implants should be positioned with approximately 3 mm between one another to ensure sufficient space for
interim implant bone and soft tissue health and to facilitate oral hygiene procedures.
 Therefore the initial marks should be separated by at least 7 mm (center to center) for 4 mm standard-
diameter implants.
 The 2-mm twist drill is used to establish the final depth of the osteotomy site corresponding to the length of
each planned implant.
 The next step is to use a series of drills to incrementally increase the width of the osteotomy site to
accommodate the planned implant diameter.
 The styles, shapes, and final diameter of the drills will differ slightly among different implant systems, but
their general purpose is to prepare a recipient site with a precise diameter (and depth) for the selected
implant without unduly traumatizing the surrounding bone.
 It is important to use copious irrigation and a “pumping” action for all drilling.
Pilot Drill

 Following the 2-mm twist drill, a pilot drill with a noncutting 2- mm–diameter
“guide” at the apical end and a cutting 3-mm– diameter (wider) midsection is
used to enlarge the osteotomy site at the coronal end, thus facilitating the
insertion of the subsequent drill in the sequence.

The 3-mm Twist Drill

 The final drill in the osteotomy site preparation for a standard diameter (4 mm)
implant is the 3-mm twist drill.
 It is the last drill used to widen the site along the entire depth of the osteotomy
from the previous diameter (2 mm) to final diameter (3 mm).
 This final drill in the sequence finishes preparing the osteotomy site and consequently is the step that dictates
whether the implant will be stable or not.
 It is critically important that the final diameter drilling be accomplished with a steady hand, without
wobbling or changing direction so that the site is not overprepared.
 Finally, depending on bone density, the diameter of this final drill may be slightly increased or decreased to
enhance implant support.
Countersink Drill (Optional)

 When it is desirable to place the cover screw at or slightly below the crestal bone,
countersink drilling is used to shape or flare the crestal aspect of the osteotomy site allowing
the coronal flare of the implant head and cover screw to fit within the osteotomy site.
 As with all drills in the sequence, copious irrigation and gentle surgical techniques are used.
Bone Tap (Optional)

 As the final step in preparing the osteotomy site in dense cortical bone, a tapping
procedure may be necessary.
 With self-tapping implants being almost universal, there is less need for a tapping
procedure in most sites.
 However, in dense cortical bone or when placing longer implants into moderately dense
bone, it is prudent to tap the bone (create threads in the osteotomy site) before implant
placement to facilitate implant insertion and to reduce the risk of implant binding.
 Bone tapping and implant insertion are both done at very slow speeds (e.g., 20 to 40 rpm).
 All other drills in the sequence are used at higher speeds (800 to 1500 rpm).
 Implant therapy may be contraindicated in some patients because of a lack of interocclusal clearance, lack of
interdental space, or a lack of access for the instrumentation.
 Therefore a combination of longer drills and shorter drills, with or without extensions, may be necessary.
Implant Placement

 Implants are inserted with a handpiece rotating at slow speeds (e.g., 25

rpm) or by hand with a wrench.
 Insertion of the implant must follow the same path or line as the osteotomy
site.
 When multiple implants are being placed, it is helpful to use guide pins in
the other sites to have a visual guide for the path of insertion.
FLAP CLOSURE AND SUTURING

 Once the implants are inserted and the cover screws secured, the surgical sites should be thoroughly irrigated
with sterile saline to remove debris and clean the wound.
 One of the most important aspects of flap management is achieving good approximation and primary closure
of the tissues in a tension-free manner.
 This is achieved by incising the periosteum (innermost layer of full-thickness flap), which is nonelastic.
 Once the periosteum is released, the flap becomes very elastic
and is able to be stretched over the implant without tension.
 One suturing technique that consistently provides the desired
result is a combination of alternating horizontal mattress and
interrupted sutures.
 Horizontal mattress sutures evert the wound edges and
approximate the inner, connective tissue surfaces of the flap to
facilitate closure and wound healing.
 Interrupted sutures help to bring the wound edges together,
counterbalancing the eversion caused by the horizontal
mattress sutures.
 For patient management, it is sometimes simpler to use a resorbable suture that does not require removal
during the postoperative visit (e.g., 4-0 chromic gut suture).
 However, when moderate-to-severe postoperative swelling is anticipated, a non resorbable suture is
recommended to maintain a longer closure period (e.g., 4-0 monofilament suture).
 These sutures require removal at a postoperative visit.
POSTOPERATIVE CARE

 Simple implant surgery in a healthy patient usually does not require antibiotic therapy.
 However, antibiotics (e.g., amoxicillin, 500 mg three times a day [tid]) can be prescribed if the surgery is
extensive or if the patient is medically compromised. Postoperative swelling is likely after flap surgery.
 This is particularly true when the periosteum has been incised (released).
 As a preventive measure, patients should apply cold packs over the first 24 to 48 hours.
 Chlorhexidine gluconate oral rinses can be prescribed to facilitate plaque control, especially in the days after
surgery when oral hygiene is typically poorer.
 Adequate pain medication should be prescribed (e.g., ibuprofen, 600 to 800 mg tid). Patients should be
instructed to maintain a relatively soft diet after surgery.
 Patients should also refrain from tobacco and alcohol use after surgery.
 Provisional restorations, whether fixed or removable, should be checked and adjusted to minimize trauma to
the surgical area.
HEALING IN DELAYED IMPLANT
PLACEMENT

 Socket healing is a well ‐orchestrated process that can be divided into three overlapping phases,
inflammatory, proliferative, and modeling and remodeling.
 During the inflammatory phase, blood clot and granulation tissue are formed while, in the proliferative
phase, new immature tissue is formed (provisional matrix and woven bone).
 In the third and final phase, modeling and remodeling, the immature tissue is removed and replaced by
mature and organized new tissue (bone marrow and lamellar bone).
 Tooth extraction promotes dimensional alterations that will result in the reduction of the alveolar ridge
volume.
 Furthermore, at extraction sites with thin buccal bone walls (< 1 mm), it is frequently observed that the bone
wall will be markedly reduced.
 It is important to note that at the anterior region of the maxilla, the average width of the buccal bone is about
0.6 mm.
 Thus, the bone modeling that takes place after tooth extraction at the buccal aspects of the sockets may lead
to esthetic problems because of loss of tissue volume.
LITERATURE REVIEW

 Misch and Judy, conducted a study on delayed implant placements, they found out that after extraction in
some cases, there are chance of buccal or facial cortical plate loss during extraction, leading to reduced bone
height and thickness for implant placement after the socket heals.
 Thereby bone height and width are reduced forcing the operator to compromise with the size and width of
the delayed implant to be placement.
(Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KW. Rationale for the application of immediate
load in implant dentistry: Part I. Implant Dent. 2004; 13: 207-17.)
 Chen et al. have analyzed the survival rates and clinical outcomes of immediate and early post extraction
implants with implants placed in healed sites (delayed placement) and concluded that there are no
statistically significant differences in terms of implant survival in the short term (12 months of follow-up)
(S. T. Chen, T. G. Wilson Jr., and C. H. F. Hämmerle, “Immediate or early placement of implants following tooth
extraction: review of biologic basis, clinical procedures, and outcomes,” International Journal of Oral and
Maxillofacial Implants, vol. 19, pp. 12–25, 2004.)
 The Quirynen’s group in a recent review on this topic leads to the same conclusion by asserting that in the
absence of long-term data, the clinical outcomes of post extraction implants and implants placed in healed
sites are practically the same.
(M. Quirynen, N. van Assche, D. Botticelli, and T. Berglundh, “How does the timing of implant placement to
extraction affect outcome?” International Journal of Oral and Maxillofacial Implants, vol. 22, supplement, pp.
203–223, 2007.)
 But, a study by Oates et al concluded that delayed implant placement can present with problems such as
marginal tissue alterations during the healing period, and papilla alterations have also been observed.
(Oates TW, West J, Jones J, Kaiser D, Cochran DL.Long-term changes in soft tissue height on the facial surface
of dental implants. Implant Dent. 2002;11:272–279.)
IMMEDIATE IMPLANT PLACEMENT

 Wound healing in an extraction socket is characterized by resorption of alveolar bone, which may result in
restorative complications.
 Healing of extraction sites when no socket preservation techniques are used, results in the resorption of an
average of 1 to 2 mm of vertical alveolar bone height and an average of 4 to 5 mm of horizontal alveolar
bone width.
 Most of this bone loss occurs during the first year after extraction, and two thirds of this bone loss occurs
within the first 3 months after extraction.
 Therefore, preservation of alveolar bone immediately after tooth extraction has an important impact on the
functional and esthetic outcomes of subsequent prosthetic treatment.
 The purpose of preserving the extraction socket is to maintain the architecture of the alveolar bone, prevent
soft tissue collapse, and minimize or eliminate the need for future bone augmentation procedures.
 Immediate implant placement is defined as the placement of an implant into the extraction socket at the time
of tooth extraction.
OUTCOME AND ADVANTAGES OF
IMMEDIATE IMPLANT PLACEMENT

 Several retrospective, prospective, and randomized, controlled clinical studies have evaluated the clinical
outcome of immediate placement in an extraction socket.
 Generally, clinical studies reported similar short-term and long-term survival rates (1–7 years) for immediate
and delayed implant placement.
 Traditional guidelines have stressed the need for complete healing of the alveolar bone before an implant is
placed into a fresh extraction socket, a process that usually requires several months.
 This lengthy undisturbed healing period extends the time of oral functional disability and substantial
resorption of the alveolar ridge may occur.
 Immediate implant placement may reduce the number of operative interventions required and the treatment
time.
 The ideal orientation of the implant may be achieved. Preserving the architecture of the hard and soft tissues
at the extraction site may provide optimal restorative esthetics
CRITERIA FOR IMMEDIATE IMPLANT
PLACEMENT

 Low-risk patient
 Low esthetic expectations
 Adequate quality and quantity of soft tissue
 Adequate quality and quantity of socket bone
 Absence of diffuse infection
 Healthy condition of adjacent teeth and supporting structures
 Primary stability
SURGICAL TECHNIQUE:

ATRAUMATIC EXTRACTION:

 Using an atraumatic extraction technique that results in minimal trauma to hard and soft tissues is a key
factor in immediate or delayed implant placement.
 Care should be taken to minimize the trauma to the gingiva
 15 c scalpel blade – sulcular incision
 Scalpel should be angled to follow the curvature of the tooth closely
 Incising interdental papilla should be avoided
 A series of thin elevators , periotomes used to separate the bone from
the labial , lingual and proximal surface of the tooth.
 This allows the removal of tooth without removing the surrounding
bone
 Using the periotome, gentle pressure is applied.
 Periotome advances more apically.
 Periotome separates the PDL and luxates the tooth.
 In molar teeth, if necessary always split the tooth with copious irrigation to section the tooth with the use of
airotor hand piece and remove the individual roots separately.
 Extraction forceps is rotated in a circular movement and the tooth pulled vertically, without pressure on the
labial bone.
 After tooth removal, a curette or an explorer is used to explore the location of the buccal plate and confirm
its integrity.
 After the tooth is removed, a spoon shaped curette is used to remove granulation tissue.
OSTEOTOMY ANS SURGICAL PLACEMENT:

 The osteotomy for an immediate placement of anterior implant could be initiated more palatally, whereas for
premolars and molars the osteotomy could be initiated toward the center of the socket.
 A small (number 2) round bur is recommended for creating the initial hole in the extraction socket before the
implant twist drills are used.
 To compensate for natural bone resorption after tooth extraction, the implant site must allow the implant to
be seated 1 to 2 mm below the margin of the intact buccal bony wall.
 If the residual jumping distance is more than 2 mm wide, a bone graft should be used.
 For adequate primary stability, immediate implants should be placed few millimeters beyond the socket or 3
to 5 mm past the apex.
 The implant must be placed at least 1 mm subcrestally, especially if the buccal or lingual plates are thin, or 2
to 3 mm below the gingival margin.
 The extraction and the placement of the implant should be flapless, when possible, or can use a sulcular
incision, 1 tooth mesial and 1 tooth distal to the implant site, which could help to expose the buccal bone.
 After immediate implant placement, the jumping distance or the horizontal gap between the implant and the
buccal surface should be filled with bone fill, if the gap is larger than 2 mm.
HEALING AFTER IMMEDIATE IMPLANT
PLACEMENT

 In a study by Araújo et al, to evaluate whether osseointegration once established following implant
placement in a fresh extraction socket may be lost as a result of tissue modeling,
 It was observed that at zero weeks the gap between the marginal portions of the implant and the walls of the
fresh socket became filled with a coagulum.
 At the 4‐week time interval, the coagulum had been replaced by newly formed bone that made direct contact
with the implant surface.
 In addition, during the first four weeks of healing
(i) the buccal and lingual bone walls underwent pronounced surface resorption,
(ii) the bundle bone in the marginal region was resorbed, and
(iii) the height of the thin buccal hard tissue wall was noticeably reduced.
 At the 12‐week time interval, it was found that the process of healing was ongoing and that the height of the
buccal bone crest was further reduced.
 The authors concluded that the early osseointegration that was established during the early phase of socket
healing following implant installation was in part lost when the buccal bone wall underwent resorption.
 Thus, the placement of implants in fresh extraction sockets in the anterior zone may represent an esthetic
risk in esthetically demanding cases since gingival recession, gingival discoloration, reduced buccal tissue
volume, and other unfavorable outcomes may occur at the site of implant placement.
LITERATURE REVIEW

 A systematic review on implants installed immediately after tooth extraction demonstrated survival
rates of more than 98% after a minimum of 1-year follow up. These results are comparable to
conventional implant placement in healed sites which showed 5-year survival rates of up to 95%
(Lang NP, Pun L, Lau KY, Li KY, Wong MC. A systematic review on survival and success rates of implants
placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Implants Res.
2012;2(5):39–66.)
 This is also in agreement with a randomized controlled clinical trial that demonstrated adequate hard
and soft tissue healing with stable marginal bone levels after 3 years of follow-up for immediate
implants placed in the anterior area
(Sanz M, Cecchinato D, Ferrus J, Salvi GE, Ramseier C, Lang NP, 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(3):321–7.)
 Results reported in the literature have shown high survival (99.1–100) and success rates (93.9–
100%) for implants placed in extraction sockets on molar areas. 
(Fugazzotto PA. Implant placement at the time of maxillary molar extraction: treatment protocols and
report of results. J Periodontol. 2008;79(2):216–23.)
 A systematic review published in 2010 reported up to 99% survival rate for immediate implants
placed in posterior areas.
(Atieh MA, Payne AG, Duncan WJ, de Silva RK. Cullinan MP immediate placement or immediate
restoration/loading of single implants for molar tooth replacement: a systematic review and meta-
analysis. Int J Oral Maxillofac Implants. 2010;25(2):401–15.)
 IMMEDIATE VS DELAYED IMPLANT
PLACEMENT

Quirynen M, Van Assche N, Botticelli D, Berglundh T. How does the timing of implant placement to extraction
affect outcome? Int J Oral Maxillofac Implants. 2007;22 Suppl:203-23.
CONCLUSION

 Several clinical studies have reported successful outcome of immediate placement of dental implants in fresh
extraction sockets.
 Although immediate implant placement has several advantages over delayed implant placement, it, like any
other procedure, is associated with risks and complications.
 Treatment protocols and guidelines should be followed to prevent complications. Case selection and
evaluation of patient-related and implant-related factors are keys to the success of immediate implant
placement.
 A thorough discussion between practitioner and patient is indispensable to discern patient’s desires.
Practitioners need to consider these desires when planning immediate, early, or delayed implant placement.
REFERENCES

 Newman and Carranza’s Clinical Periodontology, 13th edition.

 Clinical periodontology and implant dentistry, Jan Lindhe, 6 th edition.
 Misch’s contemporary implant dentistry, 4th edition
 Chen, Stephen & Buser, Daniel. (2009). Clinical and esthetic outcomes of implants placed in postextraction
sites. Int J Oral Maxillofac Implants; 24 Suppl: 186-217.
 Quirynen M, Van Assche N, Botticelli D, Berglundh T. How does the timing of implant placement to
extraction affect outcome? Int J Oral Maxillofac Implants. 2007;22 Suppl:203-23.
 Mohanad Al-Sabbagh, Ahmad Kutkut, Immediate Implant Placement Surgical Techniques for Prevention and
Management of Complications. Dent Clin N Am 59 (2015) 73–95
 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 Jun;46 Suppl 21:224-241.
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