RESEARCH ARTICLE

Immediate Placement and Restoration of Dental Implants

in the Esthetic Region: Clinical Case Series
NABIL KHZAM, BDS, MPhil, DClinDent*, NIKOS MATTHEOS, DDS, MASc, PhD, DAVID ROBERTS, BDSc, MDSc,
WILLIAM L BRUCE, BDSc, MDSc, SASO IVANOVSKI, BDSc, BDentSt, MDSc, PhD

ABSTRACT
Aim: The objective of this study was to assess the hard and soft tissue changes following immediate placement and
provisional restoration of single-tooth implants in the aesthetic zone.
Methods: Thirteen patients with immediately placed and restored implants were included in this study. All participating
patients underwent the same treatment strategy that involved removal of the failed tooth, flapless surgery, immediate
implant placement, and connection of a screw-retained provisional restoration. Three months following implant
placement, the temporary crowns were replaced by the definitive restorations. Implant survival rates, and hard and soft
tissue changes were measured using periapical X-rays and photographs. The range of the observation period was
between 12 and 37 months with a mean period of 23.2 7.6 months.
Results: At the time of follow-up, all implants were present with no complications. Radiographic evaluation revealed a
mean mesial bone gain of 1.20 1.01 mm and a mean distal bone gain of 0.80 1.14 mm, which reached statistical
significance. The mean mid-buccal recession was 0.20 0.78 mm, whereas the mesial and distal papillae height loss was
0.50 1.26 mm and 0.30 0.82 mm, respectively. The changes in the soft tissues did not reach statistical significance.
Conclusion: Notwithstanding the limitation of a small sample size, this study shows that immediate implant placement
and provisional restoration in the maxillary aesthetic zone can result in favorable treatment outcomes with regards to
soft and hard tissues changes over a follow-up period of 23.2 7.6 months.

CLINICAL SIGNIFICANCE
Most clinical trials investigating immediate implant placement and immediate restoration in the maxillary anterior zone
have focused on implant survival and implant success, with particular emphasis on radiographically assessed hard tissues
changes. However, this study assesses the soft tissue changes associated with this procedure, which is an important
area of study given the esthetic demands of implant therapy in the maxillary anterior region.
(J Esthet Restor Dent 26:332344, 2013)

INTRODUCTION
Single tooth replacement with an implant supported
crown is often the treatment of choice for missing teeth
in the anterior maxilla. The original implant treatment
protocol described by Branemark involved 3 months of

healing following extraction of a failed tooth, and an

additional 3 to 6 months of a load-free period following
implant placement.1,2 In the last 20 years, implant
dentistry has evolved dramatically, with the original
two-stage protocol modied to include one-stage
surgery,3 immediate implant placement into a fresh

*Specialist Periodontist, Private Practice, University of Tripoli, Libya

Associate Professor, The University of Hong Kong, Hong Kong

Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia

Specialist Prosthodontist, Private Practice, Brisbane, Qld, Australia

Professor of Periodontology, School of Dentistry and Oral Health, Griffith University, Gold Coast, Qld, Australia

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extraction socket and immediate implant restoration.4,5

These three approaches have been combined in an
attempt to further expedite the restorative process.6
Clinical trials have shown high levels of implant survival
and success for single tooth implants placed directly
into fresh extraction sockets.6,7 Furthermore, it has been
shown that immediately placed implants may be
provisionally restored with a temporary crown that is
placed out of occlusion (immediate provisional
restoration). This one-stage surgical and restorative
procedure has the advantage of an immediate esthetic
outcome with a xed restoration, while eliminating the
need for temporary xed and/or removable partial
dentures, and potential second-stage surgical
intervention. It also allows for shorter treatment times
as post-extraction socket-healing events coincide with
implant osseointegration. However, case selection is
critical for this treatment approach, with multiple
contraindications such as the presence of infection at
the extraction site, inadequate soft tissue prole, and
the requirement for sucient bone apical to the socket
in order to achieve appropriate primary stability.
From a surgical point of view, good primary stability
appears to be critical for the one-stage surgical
procedure, as it has been shown that there is a strong
relationship between the placement torque and the
survival of single tooth-implants.8 Adequate primary
stability is of additional importance in cases where the
implant is provisionally restored in order to withstand
various forces that may be exerted on the restored
implant during the early stages of healing. From a
restorative point of view, the implant temporary crown
must be out of occlusion in both centric and eccentric
positions of the lower jaw.6 Indeed, the immediate
implant placement and restoration protocol is
technically challenging and can be considered a
technique sensitive procedure.9
A major consideration in the maxillary anterior region
is the loss of buccal tissue contour following tooth
extraction. In order to minimize this loss of buccal
tissue, the placement of a grafting material in the space
between the implant and the buccal socket wall has
been advocated and is supported by histological

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evidence that this approach signicantly decreases bone

loss following immediate implant placement.1013 The
use of antibiotic prophylaxis in patients undergoing
routine implant placement to minimize complication is
supported by the literature and hence are indicated in
more challenging clinical protocols such as that
described in this study.14
Most clinical trials investigating immediate implant
placement and immediate restoration in the maxillary
anterior zone have focused on implant survival and
implant success, with particular emphasis on
radiographically assessed hard tissues changes.
However, few studies have assessed the soft tissue
changes associated with this procedure, although this is
an important consideration given the esthetic demands
of implant therapy in the maxillary anterior region.
Therefore, the objectives of the current study were to
assess the soft and hard tissue dimensional changes
associated with immediately placed and provisionally
restored implants replacing single teeth in the anterior
maxillary region after a minimum follow-up of
12 months.

METHODS
The research protocol was reviewed and granted ethical
approval by the Grith University Human Research
Ethics Committee (DOH/09/09/HREC).

Patient selection
Thirteen patients who received 15 immediately placed
and provisionally restored implants in the esthetic zone
between March 2007 and December 2008 were
included in this study. Two of the patients had two
implants each. Patients were included in this study
based on their willingness to attend 6 monthly review
visits following their treatment. The sample included
four males and nine females, mean age 44.7 18.7
years, with 15 implants (13 incisors, 1 canine, and 1
premolar) (Table 1). None of the patients were smokers.
No patients were lost at the nal follow-up.

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TABLE 1. Tooth types and reason for tooth extraction

Tooth type/
reason for
extraction

Endodontic

Fracture

Root
resorption

Total

Incisors

13

Canines

Premolars

Total

15

Inclusion and Exclusion Criteria

The decision to progress with immediate implant
placement and provisional restoration was determined
following a comprehensive clinical and radiographic
examination (using a cone-beam computed tomography
[CBCT] scan), and detailed consultation between the
surgical and restorative clinician. Aside from the usual
contraindications for routine implant therapy
(untreated periodontitis, uncontrolled diabetes, medical
conditions that contraindicate elective surgery), specic
contraindications for the immediate implant placement
and restoration protocol included the presence of any
pathological bone loss around the tooth or any gingival
margin pathology or irregularity. Furthermore, the
immediate implant placement and provisional
restoration protocol was not implemented unless the
tooth socket walls were completely intact (no
fenestrations or dehiscences) following extraction, and a
minimal implant torque insertion of 30 Ncm
(maximum of 40 Ncm) was obtained.

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placement followed, according to the instructions of the

implant manufacturer (Astra Tech, Mlndal, Sweden)
(Figure 1C). Primary stability was achieved to a
minimum insertion torque of 30 Ncm using a
motor-driven surgical handpiece. In all implants sites,
the buccal space between the implant and the socket
wall was lled using a xenogenic particulate bone
grafting material (Bio-Oss; Geistlich Pharma AG,
Wolhusen, Switzerland). Postoperative instructions
included chlorhexidine mouthwash (20 mL) use for
2 minutes twice daily for 2 weeks. Patients were
instructed to not brush the implant site for at least
2 weeks. For pain control, patients were advised to use
either 1 g of Paracetamol or 400 mg of Ibuprofen as
needed.

Restorative Protocol
After connection of a temporary abutment (Figure 1D),
a prefabricated screw-retained temporary crown was
adjusted and placed (Figure 1E). Appropriate
adjustment of the occlusal scheme was carried out in
order to ensure that the temporary restoration was free
of any contact in both centric and eccentric excursions
(Figure 1F). Final nishing of the provisional crown was
carried out with rubber cups and pumice. The patients
were advised to avoid placing any pressure on the
provisional restoration, especially during eating. After
3 to 4 months, the temporary restoration was replaced
with a custom zirconia abutment (Procera, Nobel
Biocare, Gteborg, Sweden) and a permanent
all-ceramic restoration by a prosthodontist.

Surgical Protocol

Hard Tissue Measurements

All surgical procedures were conducted under local

anesthesia. Preoperative antibiotics were given to all
patients. This prophylactic dose was 500 mg
Amoxicillin three times daily (20 caps) for 1 week,
starting 1 day before surgery. Diagnostic evaluation of
the site of placement included clinical examination,
radiographic analysis using a cone-beam CT scan and
occlusal analysis with study models. After informed
consent was obtained from the patient, atraumatic
tooth extraction using a periotome without ap
elevation was performed (Figure 1B). Surgical implant

Periapical X-rays were used to measure the changes in

alveolar bone height surrounding the implant from the
time of placement of the temporary restoration
(baseline) to the follow-up assessment, which was at
least 12 months later. The parallel technique was used
in order to obtain comparable X-rays, and
standardization was carried out by using the known
implant length to calibrate the baseline and follow-up
measurements. The implant shoulder was used as a
reference level from which mesial (Mbc) and distal
(Dbc) lines were drawn in an apical direction to the

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FIGURE 1. A, Failed tooth due to improper root canal treatment (12) before the extraction. B, Minimal traumatic tooth
extraction. C, Implant placed in final position. D, E, and F, Temporary crown in place. G, A radiograph.

rst point of contact between bone and the implant

(Figure 2). Computer software (Image J 1.43u; National
Institute of Health, Bethesda, MD, USA) was used to
calculate the length of these lines (Mbc and Dbc) and
express it as an absolute measurement in
millimeters.

Soft Tissue Measurements

The soft tissue data were collected from photographs
taken with a xed angle and zoom ratio prior to tooth
extraction (baseline) and at the follow-up visit (at least
12 months later). The crown length of the tooth mesial
to the implant measured from the margin of the gingiva
was set as the reference length. This allowed
comparisons of the changes that occurred before and
after the treatment with regard to the position of the
gingiva and the amount of recession. A line extending
from the incisal edges of the teeth adjacent to the
implant (Ocl) was the starting point for the
measurements. From this line, perpendicular lines were
drawn extending to the tip of the mesial (Mp) and
distal (Dp) papilla, as well as the middle of the
mid-buccal gingival margin (Bm) (Figure 3). The length

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of these lines was calculated based on the clinical

photographs using a software program (Image J 1.43u),
and variations over time were calculated in millimeters.

Other Measurements
Implant survival rate: dened as the percentage of
implants that were present at the nal follow-up.
Implant success rate: dened as the percentage of
symptom and pathology free implants at the nal
follow-up. Assessment of interdental papilla: The
triangular interdental papillae occupying the space
between the implant retained restoration and the
adjacent teeth were assessed using Jemts index.15 Jemts
Index comprises of: score 0 (no papilla present), score 1
(<1/2 of papilla present), score 2 (1/2 of papilla
present), score 3 (papilla lls entire interdental space),
and score 4 (hyperplastic papilla present).

Statistical Analysis
The primary hypothesis of this study was that there is
no signicant change between tooth extraction/implant
placement and follow-up with regards to the hard and

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FIGURE 3. Illustration of the measurements of soft tissue on

photographs. Bm = distance to middle of buccal gingival margin;
Dp = distance to distal papilla; Mp = distance to mesial papilla;
Ocl = occlusal line.

demographics, implant characteristics and follow-up

intervals are shown in Table 2. No implant loss or
implant associated pathology was observed at
the nal follow-up visit. Representative
outcomes of the treatment are illustrated in
Figures 4 to 6.
FIGURE 2. Illustration of hard tissue measurements on
periapical X-ray. Cl = coronal line; Dbc = distal bone contact;
Mbc = mesial bone contact. A set of paired radiographs used
for measurements. A = baseline radiograph; B = follow-up
radiograph.

soft tissues changes. In case of parametric data, a paired

t-test was used, whereas in nonparametric data a
Wilcoxon signed-rank test was used. A frequency
analysis was used to describe the distribution of hard
and soft tissue changes among the patients. All
calculations were performed with the SPSS statistical
software program (version 16.0, SPSS, Inc., Chicago, IL,
USA).

Hard Tissue Measurements

Radiographic evaluation revealed a mean mesial bone
gain of 1.20 1.01 mm (p < 0.0001), which reached
statistical signicance. The mean distal bone gain was
0.80 1.14 mm (p = 0.01), which also reached statistical
signicance. Table 3 shows that there was a signicant
change in both the mesial and distal bone level between
the time of implant placement and the follow-up
assessment. Table 4 shows the distribution of bone gain
and loss in millimeters for individual patients. The
majority of the readings demonstrated bone gain
0.5 mm (13/15 cases).

Soft Tissue Measurements

RESULTS
The reasons for tooth loss of the 15 implants (13
incisors, 1 canine, and 1 premolar) included in this
study are outlined in Table 1. The patient

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The mean mid-buccal gingiva recession was 0.20 0.78

mm (p = 0.44). The mesial papillary height loss was
0.50 1.12 mm (p = 0.24), whereas the distal papillary
height loss was 0.30 0.82 mm (p = 0.27) Table 5. The

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TABLE 2. Overview of clinical data

Patient No.

Sex

Age
(years)

Follow-up
(months)

Site of
implant

Length
(mm)

Diameter
(mm)

39

30

11

15

5.0

39

30

21

13

4.0

23

16

11

15

5.0

33

20

11

13

4.5

33

20

21

15

4.5

62

21

21

13

5.0

66

26

14

13

4.0

64

17

12

13

3.5

27

28

13

15

4.0

10

44

31

21

13

4.5

11

27

30

22

15

4.0

12

83

37

22

15

4.0

13

62

12

11

13

4.0

14

32

15

21

13

5.0

15

66

18

22

15

4.0

M = male, F = female.

mesial papilla showed the highest amount of tissue loss.

The changes in the soft tissues did not reach statistical
signicance. Table 6 shows the distribution of soft tissue
changes on the mesial, distal, and mid-facial aspects of
individual implants. Most of the readings remain within
10% of the baseline value except for the mesial
changes which reach up to 35% in the patients that had
two implants placed adjacent to each other.

Jemts Index
Wilcoxon signed-rank test did not reveal any signicant
dierence in the Jemts index score for either mesial or
distal papilla between implant placement and follow-up
observations (p-values 0.180 and 0.171, respectively)
(Table 7). At follow-up, 50% of the mesial papillae
received a score of 3, which means that the full height
of the interdental papillae was present (normal),
whereas the same score was recorded in 60% of distal

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papillae. The rest of the results showed scores of 1, 2,

and 4. No score of 0 was recorded.

DISCUSSION
In this case series report, immediately placed and
restored single-tooth implants in the maxillary anterior
zone were found to osseointegrate and remain
complication-free after 23.2 7.6 months of follow-up.
This result is in accordance with outcomes presented in
other similar studies,1622 demonstrating the high
predictability of osseointegration when a very specic
set of selection criteria is applied, and a strict surgical
and restorative protocol is observed.
This study utilized the Astra Tech implant system,
which has several abutment-implant interface
characteristics common to contemporary implant

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FIGURE 4. Illustration of soft tissue on photographs,

(22)-base line(A) and follow-up(B).

FIGURE 5. Illustration of soft tissue on photographs,

(21)-base line (A) and follow-up (B).

systems. Astra Tech implants have a rough surface, an

internal connection, a platform switch at the
abutment-implant interface and microthreads at the
coronal aspects of the implant. These design features
are incorporated primarily to enhance the stability of
the hard and soft tissues, although it is unclear if, and
to what extent, each of these features may contribute to
tissue stability. It is likely that some or all of the
features of the Astra Tech system, many of which it
shares with other currently available implant designs,
has contributed to the positive outcomes of this
study.

This is not surprising because the implants were placed

in extraction sockets, and there was subsequent bone
ll in the space between the implant and the socket
walls, resulting in the coronal repositioning of the
bone-implant contact over the course of the study. The
bone gain was also assisted by the use of a slowly
resorbing particulate bone graft.

This study showed a mean mesial bone gain of 1.20 mm

and a mean distal bone gain of 0.80 mm over the
duration of the follow-up period (23.2 7.6 months).
The changes in the hard tissues reached statistical
signicance compared with baseline suggesting that
there was bone gain in a coronal direction at the
interproximal aspects over the duration of the study.

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Knowing the exact implant length and diameter allowed

for precise measurement of the bone level in
millimeters, compensating for any distortion of the
radiograph. This was an important element of the
methodology in contrast with much of the literature,
where measurements are only made with the use of the
apical20,22 or the coronal end23 of the implant shoulder
as a reference point. Other studies have used the
contact point of the restoration to the adjacent tooth as
a reference point. However, the use of these landmarks
has some limitations, namely that the restorative
contact point is not going to be constant as the

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TABLE 4. Frequency analysis of hard tissue changes in

millimeters

Bone changes in
mm/patients

2.5 and 2 mm

2.23

2.19

2.18

2 and 1.5 mm

1.79

1.75

1.58

1.5 and 1 mm

1.29

1.04

1 and 0.5 mm

0.82

0.71

0.5 and 0 mm

0.22

0.2

0.01

0 and 0.5 mm

0.09

0.5 and 1 mm

0.63

TABLE 5. Soft tissue level changes (presented as millimeters

change)
Parameters

Change in mm

p-value

Mesial papilla level

0.50 1.12

0.24

Distal papilla level

0.30 0.82

0.27

Mid-buccal ginigval level

0.20 0.78

0.44

Mean standard deviation.

FIGURE 6. Illustration of soft tissue on photographs,

(21)-base line (A) and follow-up (B).
TABLE 3. Bone level changes (presented as millimeters
change)
Parameters

Change in mm

p-value

Mesial bone level

1.20 1.01

0.001*

Distal bone level

0.80 1.14

0.01*

Mean standard deviation.

*Significant.

provisional crowns will undergo replacement with

permanent restorations, whereas the radiographic
location of the apical/coronal shoulder is easily aected
by image distortion.24
The results of the present study, which showed a
relatively high amount of bone gain, compares favorably
with other studies involving implant therapy in the
maxillary anterior zone.18,19,22,2528 Using the immediate

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placement and restoration protocol, Kan and colleagues

showed a mean marginal bone loss ranging from 0.26 to
0.40 mm on the mesial and 0.22 to 0.28 mm on the
distal aspect of the implant at 1-year follow-up.23
Several other investigators have shown even greater
amounts of bone loss. The study by De Rouck and
colleagues revealed a mean bone loss of 0.98 mm on the
mesial aspect of the implant and 0.78 mm distally at
1-year follow-up.6 Other studies using the immediate
implant placement and immediate restoration approach
have shown similar outcomes.23,24,2931 On the other
hand, Kan and colleagues reported that scalloped
shaped implants placed into extraction sites showed a
mean bone gain of 1.0 mm after 1 year of follow-up.7
The amount of bone gain in this study was attributed to
the placement of a bone graft into the gap between the
implant and walls of the extraction socket that
subsequently resulted in radiographically assessed bone
ll. Our study used a platform switching implant

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TABLE 6. Frequency analysis of soft tissue changes in percentage

Soft tissue changes in
percentage/Patients
10% and 5%

5.96 (DP)

5.90 (MP)

5.12 (MP)

7.70 (MF)

5.95 (MF)

1.02 (DP)

2.06 (DP)

1.79 (MP)

0.11 (MP)

1.83 (MF)

4.58 (MF)

0.95 (MF)

4.5 (MF)

2.57 (DP)

1.62 (DP)

1.13 (DP)

1.82 (DP)

0.36 (DP)

2.31 (DP)

0.72 (MP)

1.14 (MP)

0.96 (MP)

0.39 (MF)

1.09 (MF)

4.72 (MF)

8.98 (DP)

9.55 (DP)

7.43 (DP)

9.03 (DP)

9.55 (MF)

8.05 (MF)

9.99 (MF)

10.76 (MP)

10.63 (MP)

14.95 (MP)

13.41 (MF)

12.86 (MF)

15% and 20%

18.52 (DP)

20% and 25%

24.68 (MP)

25% and 30%

25.92 (MP)

30% and 35%

33.17 (MP)

5% and 0%

0% and 5%

5% and 10%

10% and 15%

DP = distal papilla; MF = mid-facial gingival; MP = mesial papilla.

TABLE 7. Changes in the interdental papilla

Parameters

Amount of change

p-value

Mesial papilla level

1.342*

0.180

Distal papilla level

1.242*

0.171

*Z value

design, apless surgery, and applied a particulate bone

graft between the tooth socket and the implant, which
may account for the reported increase in interproximal
bone height over the observation period.
Soft tissue measurements have been reported in only a
few studies utilizing immediate placement and

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immediate provisional restoration of implants in the

anterior maxilla. This study showed mean mid-buccal
gingival recession of 0.20 mm, whereas the mesial and
distal papillae were apically positioned by 0.50 and
0.30 mm respectively, compared with baseline. Overall,
no statistically signicant changes in the aesthetically
important mid-buccal soft tissue prole were found
compared with baseline. Furthermore, no statistically
signicant changes in papilla levels were noted when
the results were accurately measured in millimeters.
This indicates a short-medium term stability of the soft
tissue architecture around immediately placed and
restored implants. The soft tissue loss noted in this
study was of minimal clinical signicance and did not
appear to inuence the esthetic outcome. This is
further supported by the fact that there were no

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dierences in Jemts index indicating no changes in the

papillary ll of the interdental embrasure, which is of
importance in terms of the esthetic outcome.15 It should
also be noted that there was apical drift of the mesial
papillae more than that of the distal papillae and
mid-facial tissue. The greater mesial papilla tissue loss
can be attributed to the fact that the sample included
four implants replacing both central incisors in two
patients. In this case, the mesial papillae were bordered
by implants on both sides, and it is widely recognized
that greater soft tissue loss occurs between two
implants compared with an implant and an adjacent
natural tooth.32
The method being used for this study to record soft
tissue measurements is dierent from other
studies,23,25,27 which used a reference line connecting the
mid-facial gingival level of the two teeth adjacent to the
implant restoration. However, ap elevation was used
for access in these studies, which may lead to variability
of the position of the reference line connecting the
mid-facial gingiva of the adjacent teeth, as some soft
tissue recession generally occurs following the elevation
of a full mucoperiosteal ap. The reference line used in
our study extended from the incisal edges of the teeth
adjacent to the implant, and this acted as a xed and
stable reference.
The soft tissue outcomes reported in this study
compare favorably with the available literature. In a
study that assessed 35 patients with single immediately
placed and restored maxillary implants, the soft tissue
loss from the facial aspect was greater than that
reported in our study, with 0.55 mm loss at the
follow-up period of 1 year.23 Similar results were
reported by De Rouck and colleagues with an average
mid-buccal recession of 0.53 mm in the rst year of
function.6 Another study by Cornelini and
colleagues reported 0.75 mm mid-facial tissue loss after
1 year.27 The somewhat superior outcomes reported in
this study may be attributable to dierences
in implant design (platform switch versus regular
platform, internal versus external attachment) and
surgical protocols (ap elevation versus apless,
augmentation of gap between implant and
socket walls).

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In terms of longer term changes, a recent paper

published by Cosyn and colleagues revealed a mean
mesial and distal papilla height loss of 0.05 and
0.08 mm, respectively.30 The mid-facial soft tissue
recession was 0.34 mm. The mesial papillae showed
signicant regrowth between the 1- and 3-year
follow-ups. Advanced midfacial recession was found in
2/25 (8%) cases.30 Kan and colleagues showed that
following a 4-year follow-up period, the changes in
mean mesial and distal papilla levels (0.22 and
0.21 mm, respectively) were signicantly less than
those observed at the 1-year follow-up. However, the
mean overall facial gingival level change (1.13 mm)
was signicantly greater than that observed at the
1-year follow-up (0.55 mm), which means that
papillary height may improve over time, although
changes in the position of the labial margin may
deteriorate.32 Therefore, long-term studies are required
to document the long-term esthetic outcomes of
implant treatment in the anterior maxillary region.
In comparison with other treatment protocols, studies
with data on the soft tissue changes following single
tooth implant placement in healed sockets reveal
around 0.6 mm of mid-facial recession within the rst
year of placement.33,34 In a study using the conventional
technique (two stages) with a follow-up period of 3
years, the mean recession on the mid-facial aspect of
the implant was found to be 1 mm.35
Overall, the results of the present investigation
demonstrate a relatively limited loss of soft tissue on
the mid-facial aspect. This fact can be attributed to
atraumatic extraction of the failed teeth, apless
surgical approach, and the use of a particulate
xenograft. It is noteworthy that apless surgery presents
increased risk for perforation of the alveolar bone, and
the experience of the surgeon is an important factor
that minimizes that risk.36 Insertion of bone grafting
material (Bio-Oss) into the gap between the implant
and the walls of the extraction socket assists in
preserving a stable level of the hard tissues,13 and hence
the overlying soft tissue prole, as the Bio-Oss particles
would not signicantly resorb over the duration of the
study. Finally, the use of screw-retained instead of
cemented temporary restorations may contribute to the

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IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.

absence of complications during the initial stages of

wound healing and maturation. In contrast, stula
formation was reported in a study conducted by Kan
and his associates using a cemented type of temporary
crowns.19 It is important to note that mid-facial
recession does not necessarily imply an esthetic
compromise. An interesting nding in one case (FR)
was that the recession at the mid-facial aspect actually
improved the patient esthetic, as the level of the
adjacent tooth buccal soft tissue was already apically
displaced (Figure 6).

period and a larger sample size are needed to support

more denite conclusions.
Notwithstanding the limitations of the study, the results
indicate that the immediate placement and provisional
restoration of a single tooth implant in the anterior
maxilla can result in predictable implant
osseointegration, as well as stable peri-implant tissues,
for up to 23.2 7.6 months.

DISCLOSURE
The papillary height changes observed in this study
appear to be in accordance with other studies. Kan and
colleagues reported a mean loss of 0.50 mm for the
mesial papillae and 0.30 mm mean loss of the distal
papillae.23 De Rouck and his associates showed a
reduction in the papillae height loss of 0.41 mm on
average for mesial papillae and 0.31 mm for distal
papillae.6
No statistically signicant dierences were found
between the papillae levels at baseline and follow-up in
terms of Jemts index.15 A study by Cornelini and
colleagues found no scores of 0, 1, or 4 in their sample,
with 60% of papillae receiving a score of 2, with the
remainder scoring a 3.27 In another study by Kan and
colleagues the papilla index was measured at
pretreatment and 3, 6, and 12 months following implant
placement with no dierences noted between baseline
and any of the follow-up observations.7 Therefore, the
ndings of our study in relation to Jemt s index are
consistent with the published literature.
This clinical investigation was limited by the
retrospective nature, the small sample size, the inability
to secure a fully standardized follow-up examination
protocol for all patients and the relatively small length
of the observation period. All of these factors can have
a signicant impact on the results obtained from this
study, which should be interpreted with caution.
Nevertheless, the study has provided some indications
as to the nature and extent of soft and hard tissue
changes that may be expected with this protocol,
although it remains unclear if the soft tissue outcomes
would remain stable over time. A longer observation

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The authors have no nancial interest in any of the

companies whose products are mentioned in this paper.

REFERENCES
1.

2.

3.

4.

5.

6.

7.

8.

Albrektsson T, Branemark PI, Hansson HA, Lindstrom J.

Osseointegrated titanium implants. Requirements for
ensuring a long-lasting, direct bone-to-implant anchorage
in man. Acta Orthop Scand 1981;52:15570.
Branemark PI, Adell R, Albrektsson T, et al.
Osseointegrated titanium xtures in the treatment of
edentulousness. Biomaterials 1983;4:258.
Becker W, Becker BE, Israelson H, et al. One-step surgical
placement of Branemark implants: a prospective
multicenter clinical study. Int J Oral Maxillofac Implants
1997;12:45462.
Lazzara RJ. Immediate implant placement into extraction
sites: surgical and restorative advantages. Int J
Periodontics Restorative Dent 1989;9:33243.
Gomes A, Lozada JL, Caplanis N, Kleinman A. Immediate
loading of a single hydroxyapatite-coated threaded root
form implant: a clinical report. J Oral Implantol
1998;24:15966.
De Rouck T, Collys K, Cosyn J. Immediate single-tooth
implants in the anterior maxilla: a 1-year case cohort
study on hard and soft tissue response. J Clin Periodontol
2008;35:64957.
Kan JY, Rungcharassaeng K, Liddelow G, et al.
Periimplant tissue response following immediate
provisional restoration of scalloped implants in the
esthetic zone: a one-year pilot prospective
multicenter study. J Prosthet Dent 2007;97(6 Suppl):
10918.
Esposito M, Grusovin G, Achile H, et al. Interventions for
replacing missing teeth: Dierent times for loading dental
implants. Cochrane Database Syst Rev
2009;(1):CD003878.

DOI 10.1111/jerd.12083

2013 Wiley Periodicals, Inc.

IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

Chaushu G, Chaushu S, Tzohar A, Dayan D. Immediate

loading of single-tooth implants: immediate versus
non-immediate implantation. A clinical report. Int J Oral
Maxillofac Implants 2001;16:26772.
Neves M, Correia A, Alves CC. A novel approach to
preserve the buccal wall in immediate implant cases: a
clinical report. J oral implant 2013;39(2):198205.
Cornelini R, Scarano A, Covani U, et al. Immediate
one-stage postextraction implant: a human clinical and
histologic case report. Int J Oral Maxillofac Implants
2000;15:4327.
Botticelli D, Berglundh T, Lindhe J. Hard-tissue
alterations following immediate implant placement in
extraction sites. J Clin Periodontol 2004;31:8208.
Araujo MG, Linder E, Lindhe J. Bio-Oss collagen in the
buccal gap at immediate implants: a 6-month study in the
dog. Clin Oral Implants Res 2011;22(1):18.
Esposito M, Grusovin MG, Worthington HV.
Interventions for replacing missing teeth: antibiotics at
dental implant placement to prevent complications.
Cochrane Database Syst Rev 2013;(7):CD004152.
Jemt T. Regeneration of gingival papillae after
single-implant treatment. Int J Periodontics Restorative
Dent 1997;17:32633.
Vandeweghe S, Nicolopoulos C, Thevissen E, et al.
Immediate loading of screw-retained all-ceramic crowns
in immediate versus delayed single implant placement.
Int J Prosthodont 2013;26(5):45864.
Raes F, Cooper LF, Tarrida LG, et al. A case-control study
assessing oral-health-related quality of life after
immediately loaded single implants in healed alveolar
ridges or extraction sockets. Clin Oral Implants Res
2012;23(5):6028.
De Bruyn H, Raes F, Cooper LF, et al. Three-years clinical
outcome of immediate provisionalization of single
Osseospeed() implants in extraction sockets and healed
ridges. Clin Oral Implants Res 2013;24(2):21723.
Cooper LF, Raes F, Reside GJ, et al. Comparison of
radiographic and clinical outcomes following immediate
provisionalization of single-tooth dental implants placed
in healed alveolar ridges and extraction sockets. Int J Oral
Maxillofac Implants 2010;25(6):122232.
Calvo Guirado JL, Saez Yuguero R, Ferrer Perez V,
Moreno Pelluz A. Immediate anterior implant placement
and early loading by provisional acrylic crowns: a
prospective study after a one-year follow-up period. J Ir
Dent Assoc 2002;48:439.
Canullo L, Rasperini G. Preservation of peri-implant soft
and hard tissues using platform switching of implants
placed in immediate extraction sockets:
a proof-of-concept study with 12- to 36-month
follow-up. Int J Oral Maxillofac Implants
2007;22:9951000.

2013 Wiley Periodicals, Inc.

DOI 10.1111/jerd.12083

22. Hui E, Chow J, Li D, et al. Immediate provisional for

single-tooth implant replacement with Branemark
system: preliminary report. Clin Implant Dent Relat Res
2001;3:7986.
23. Kan JY, Rungcharassaeng K, Umezu K, Kois JC.
Dimensions of peri-implant mucosa: an evaluation
of maxillary anterior single implants in humans.
J Periodontol 2003;74:55762.
24. Tsirlis AT. Clinical evaluation of immediate loaded upper
anterior single implants. Implant Dent 2005;14:94103.
25. Ferrara A, Galli C, Mauro G, Macaluso GM. Immediate
provisional restoration of postextraction implants for
maxillary single-tooth replacement. Int J Periodontics
Restorative Dent 2006;26:3717.
26. Norton MR. A short-term clinical evaluation of
immediately restored maxillary TiOblast single-tooth
implants. Int J Oral Maxillofac Implants 2004;
19:27481.
27. Cornelini R, Cangini F, Covani U, Wilson TG Jr.
Immediate restoration of implants placed into fresh
extraction sockets for single-tooth replacement: a
prospective clinical study. Int J Periodontics Restorative
Dent 2005;25:43947.
28. Palattella P, Torsello F, Cordaro L. Two-year prospective
clinical comparison of immediate replacement vs.
immediate restoration of single tooth in the esthetic zone.
Clin Oral Implants Res 2008;19:114853.
29. Lorenzoni M, Pertl C, Zhang K, et al. Immediate loading
of single-tooth implants in the anterior maxilla.
Preliminary results after one year. Clin Oral Implants Res
2003;14:1807.
30. Cosyn J, Eghbali A, De Bruyn H, et al. Immediate
single-tooth implants in the anterior maxilla: 3-year
results of a case series on hard and soft tissue
response and aesthetics. J Clin Periodontol
2011;38(8):74653.
31. Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman G.
Facial gingival tissue stability following immediate
placement and provisionalization of maxillary anterior
single implants: a 2- to 8-year follow-up. Int J Oral
Maxillofac Implants 2011;26(1):17987.
32. Tarnow DP, Cho SC, Wallace SS. The eect of
inter-implant distance on the height of inter-implant
bone crest. J Periodontol 2000;71:5469.
33. Cardaropoli G, Lekholm U, Wennstrom JL. Tissue
alterations at implant-supported single-tooth
replacements: a 1-year prospective clinical study. Clin
Oral Implants Res 2006;17:16571.
34. Grunder U. Stability of the mucosal topography around
single-tooth implants and adjacent teeth: 1-year results.
Int J Periodontics Restorative Dent 2000;20:117.
35. Choquet V, Hermans M, Adriaenssens P, et al. Clinical
and radiographic evaluation of the papilla level adjacent

Journal of Esthetic and Restorative Dentistry

Vol 26 No 5 332344 2014

343

IMMEDIATE PLACEMENT AND RESTORATION OF DENTAL IMPLANTS Khzam et al.

to single-tooth dental implants. A retrospective study in

the maxillary anterior region. J Periodontol
2001;72:136471.
36. Oh TJ, Shotwell J, Billy E, et al. Flapless implant
surgery in the esthetic region: advantages and
precautions. Int J Periodontics Restorative Dent
2007;27:2733.

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DOI 10.1111/jerd.12083

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