Navigating life together

Author AcknowledgementsGUY HUYNH-BA, DDS MSAssociate Professor/ClinicalDepartment of PeriodonticsUT Health San AntonioSchool of DentistrySan Antonio, TX

Dr. Huynh-Ba has no relevant relationships to disclose.

The following commentary highlights fundamental and commonly accepted practices on the subject matter. The information is intended as a general overview and is for educational purposes only. This information does not constitute legal advice, which can only be provided by an attorney.

© Metropolitan Life Insurance Company, New York, NY. All materials subject to this copyright may be photocopied for the noncommercial purpose of scientific or educational advancement.

Originally published July 2014. Updated and revised December 2017. Expiration date: December 2020.

The content of this Guide is subject to change as new scientific information becomes available.

Educational ObjectivesFollowing this unit of instruction, the learner should be able to:

1. Describe the different timings of implant placement.

2. Describe the outcomes of immediate implant placement.

3. Recognize the prevalence of mid facial mucosal recession around immediate implants.

4. Identify the risks factor for mid-facial mucosal recession.

5. List clinical guidelines to decrease risk for mid-facial mucosal recession.

6. Identify treatment alternative to immediate implant placement.

Timing of Implant PlacementThe use of dental implants to replace missing teeth has been universally accepted based on a large body of scientific evidence since the early 1970s. While the initial guidelines published by Brånemark and coworkers (1977)1 required implants to be placed in healed alveolar ridges, the improvement in implant surface technology and understanding of wound healing around dental implant have allowed the development of more time efficient treatment protocol.

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MetLife designates this activity for 1.0 continuing education credits for the review of this Quality Resource Guide and successful completion of the post test.

Second Edition

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Quality Resource Guide

Immediate Dental Implants

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or not, of therapy. For example the case depicted in Figure 1 illustrates an implant that would be considered as a positive outcome if survival is the outcome measured. However, to the patient eyes this situation is an esthetic failure.

From a surgical standpoint, the climax of these developments is represented by immediate implant placement, i.e. the implant is placed in the same procedure as the extraction.

Different classifications of timing of implant placement have been described.2,3 The terminology used in the present article uses the definitions established by the International Team for Implantology (ITI).3 This classification is based on the desired clinical outcome during the post extraction healing period quality of healing of the extraction socket.

Type 1: Tooth extraction and implant placement take place during one single dental appointment

Type 2: The extraction site is left to heal for 4 to 8 weeks allowing soft tissue healing over the extraction site before implant placement

Type 3: Following tooth extraction the site has healed for 12 weeks allowing for complete healing of the soft tissue and partial bony healing of the extraction socket.

Type 4: Represents the implant placement in healed sites, similar to the Brånemark protocol.

Implants placed in a healed ridge (type 4) probably represent the most conservative approach and is widely propagated, especially in conjunction with ridge preservation procedure (SEE QRG Huynh-Ba Ridge preservation).

Outcomes Assessment of Type 1 Implant PlacementThe outcomes of immediate implant placement (Type 1) has been documented as a predictable, safe and effective approach to replace extracted teeth, with survival rates greater than 95% in longitudinal studies up to 10 years.3-12 In comparative trials immediate implant placement (Type 1) and implant placement in healed ridges (Type 4) yielded similar survival rates without any statistical significant difference.13-16

While these results are encouraging, the assessment outcome (survival rate) falls short when trying to reflect patient satisfaction with a given procedure. Indeed, the patient may rely more on the subjective esthetic perception of an implant supported restoration to evaluates the outcomes, successful

Risk Indicators of RecessionsSeveral putative risk factors have been associated with the development of soft tissues recessions around immediate implants including a non-intact facial plate following extraction, a thin buccal plate, a facial positioning of the implant and thin periodontal phenotype. The paragraphs below present some relevant literature for each of these risk factors and some suggested clinical strategies in order to control them.

• Loss of buccal plate integrity:Prior to implant placement, the least traumatic extraction (see QRG on Atraumatic tooth extraction) must be performed with the goal to maintain the integrity of the socket bone walls. This is of paramount importance since it has been shown that the presence of a dehiscence defect of the buccal plate at the extraction led to a significant amount of buccal plate resorption, which in turn can lead to recession.21,22, 28-30 Therefore, in case the integrity of the socket bone walls was not maintained, it is recommended to reconstruct the alveolar ridge and place the implant in a staged approach.31

• Thin buccal plate: Pre-clinical and clinical studies have convincingly demonstrated that the pattern of alveolar ridge resorption and remodeling following tooth extraction was influenced by the width of the buccal plate. Due to the thin nature of the buccal plate, especially in maxillary anterior sites,32-35 ridge resorption will decrease the width of the alveolar ridge and a loss of the vertical height of the buccal plate is expected following tooth extraction.36-42 It is important to mention that the sole placement of a dental implant in the extraction socket cannot prevent these physiological changes from happening.15, 43-46 Moreover, emerging evidence seems to indicate that these dimensional changes are not affected by the implant surface characteristics.47

Grafting the residual horizontal defect present between the implant and the internal wall of the buccal extraction socket to compensate for the resorption of the buccal plate has been proven successful and has become common clinical practice.17,48,49 Some studies have suggested that bone grafting on the external aspect of the buccal

Clinical picture illustrating an esthetic failure following immediate implant placement at site #10 (Courtesy of Dr. Brian Mealey, DDS, MS)

Figure 1

In an effort to address this shortcoming many studies have reported esthetic outcomes of dental implant therapy including the level of the mid-facial mucosal margin.

Soft Tissue ManagementMany immediate dental implants are placed in the anterior region so a patient may maintain the appearance of an intact dentition. Several factors must be carefully considered during planning and therapy in an attempt to minimize tissue recession and maximize the esthetic outcome.

Immediate Implants and RecessionsOne of the major esthetic concerns following immediate implant placement is the recession of the facial peri-implant mucosa. The incidence of peri-implant mucosal recession (up to 1mm) reported ranges between 8 and 40%.4,10,17-26

Some of these studies reported up to 2mm of peri-implant mucosal recession following immediate implant placement, leading to discrepancies between the positions of soft tissue margins around the implant supported restoration and its contralateral natural counterpart. In esthetic sensitive areas, this loss of symmetry leads to unpleasant esthetic outcomes.27

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plate, also known as over-contouring, will increase the thickness of buccal bone wall and possibly maintain soft tissue stability over time.50, 51

• Buccal positioning:Chen, et al. (2007)17 convincingly demonstrated that the main factor related mucosal buccal recession following immediate implant placement was the implant shoulder placed too facially in relation to the emergence profile of adjacent teeth. These findings were further confirmed by other clinical studies.19, 42, 52, 53

In a healed ridge, the guidelines for placement of a dental implant in the bucco-lingual position recommend to have the implant bed prepared in such a way that the implant shoulder is positioned about 1 mm palatal to the point of emergence at adjacent teeth.29,54 Given the previously mentioned dimensional changes following tooth extraction, it becomes obvious that the positioning of an immediate implant in a correct oro-facial position has to be adapted to these specific healing patterns. Therefore, it has been suggested that implant shoulder should be placed approximately 2mm palatally to the point of emergence at adjacent teeth.17, 31

• Periodontal phenotype: Traditionally, the gingival phenotype characterized the quality of the soft tissue around teeth taking in account four parameters including the width of keratinized tissue, the gingival thickness, the shape and size of the interdental papillae and the crown width/height ratio. Usually a thin gingival phenotype is associated with a limited amount of keratinized tissue, a thin gingiva with long interdental papillae creating a marked gingival scalloped architecture and reduced crown width/height ratios, i.e. triangular shaped teeth. Conversely, a thick gingival phenotype is associated with large zones of keratinized tissue, a thick gingiva, short interdental papillae with a flat gingival architecture and an increased crown width/height ratio or squared shaped teeth.30, 55, 56

Teeth with a thin gingival phenotype have been shown to respond less favorably to periodontal procedures including regenerative periodontal surgery55 and gingival recession coverage.57 Similarly, individuals with a thin gingival phenotype had less favorable soft tissue esthetic outcomes following implant therapy.12,18,58,59

The explanation as to why patient with a thin periodontal tissue phenotype may be at greater risk for mucosal recession following immediate dental implants may lay in the fact that a thin periodontal tissue phenotype is associated with a thinner underlying buccal plate thickness as compared to a thick phenotype.60,61 This, in turn, reinforces the importance of the buccal plate thickness and its potential role in the development of mucosal recession following immediate implant placement.

Recession CoverageSince mucosal recessions around immediate implants are fairly prevalent, a legitimate question that may arise is if, similarly to gingival recession on teeth, mid-facial soft tissue recession coverage on implants can be attempted using traditional periodontal plastic surgery strategies.

In a case series published by Burkhardt and Lang (2008)62,10 patients who displayed mid-facial recession (range: 1.9mm to 4.7mm) around a single implant in the anterior maxilla were treated using a connective tissue graft and a coronally advanced flap. While complete coverage was achieved immediately after surgery 8 case out of ten, over time soft tissue shrinkage was observed. The mean recession coverage achieved at 6 months, was 78.6% and none of the treated site presented with full recession coverage. The authors concluded that while improvement can be expected, recession coverage around implants is not predictable. Along the same line, a recent article by Levine, et al. (2014)63 prepared for the 5th International Team for Implantology Consensus Conference (Bern, Switzerland, April 2013) ) reviewed the available evidence for soft tissue augmentation procedures to treat peri-implant mucogingival defects. The essence of the review indicated that recession coverage around implants is at best unpredictable and that good scientific support is lacking in the treatment of these particular conditions.

Taken together, it can be concluded that preventive strategies should be implemented to avoid mucosal recession as no scientifically sound established treatment protocol is available at present to treat these unfavorable outcomes.

Clinical Considerationsa) AnatomyOne of the requirements for successful immediate implants is the ability to achieve primary stability upon implant placement. Usually, the implant diameter is generally smaller than the dimensions of the tooth root. As a corollary, it is the amount of native bone engaged during implant bed preparation beyond the confines of the socket that will determine the surgeon’s ability to obtain primary stability.

Typically, the available bone apically to the root should be examined to ascertain that a least a couple of millimeters are present. This is mainly limited by the anatomy of surrounding vital structures such as the maxillary sinus and floor of the nose in the maxilla and the inferior alveolar nerve in the mandible.

In the anterior maxilla, it is not unusual to have the implant displaced slightly palatally to allow a screw-retained implant supported restoration with an access channel going through the cingulum of the tooth and to avoid a common cause of facial recession, i.e. facially placed implants. In this case, a cone beam computed tomography (CBCT) can be recommended to allow the evaluation of the amount of bone available palatally to the root of the tooth in the oro-facial plane.

A study by Kan et al. (2011) 64 showed that 81.1% of the roots of anterior maxillary teeth, i.e. canine to canine, are positioned against the labial plate. Therefore, in a majority of the cases the placement an immediate implant in the anterior maxilla in a palatal position is possible. Conversely, 1 maxillary anterior tooth out 20 might present very limited amount of bone available palatal to the root which might prevent immediate implant placement.

b) Periapical infectionThe presence of a hopeless tooth with a chronic periapical infection does not represent a contraindication to immediate implant placement. Two independent randomized controlled clinical trials have clearly demonstrated that chronic periapical endodontic lesions do not impact the survival rate if immediate implant therapy.29,65,66.

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The clinical recommendation is to ensure adequate removal of the granulation tissue around the lesion and rinsing with saline solution for proper debridement of the lesion. Moreover, the presence of a buccal fenestration at the site of the lesion should be treated, following implant placement, by guided bone regeneration (GBR) using a bone graft material covered by a resorbable membrane.66

c) Patient related factorsAmong the factors to be considered patients expectation and patient smile line should be evaluated. High esthetic expectations and a high smile line would leave very little margin for errors and even a 0.5mm mid-facial recession may be deemed as unsatisfying to the eyes of a patient with high esthetic demands.

d) Soft tissue grafting at the time of implant placementMany different techniques have been advocated to increase the thickness and the quality of the soft tissue around dental implants. However, the evidence to support an added benefit from these procedures is limited, weak and , therefore, cannot not be recommended as standard care.67,68

Alternative to (Type 1) Immediate Implant PlacementThe type 2 implant placement protocol as described by Buser, et al. (2008)69 represents a valid alternative to Type 1 implant placement. The readers are invited to refer to the original article describing this technique for more details. In brief, following tooth extraction a collagen plus is placed into the extraction socket and the site is left to heal to allow the soft tissue closure over the extraction socket. Four to 8 weeks later, implant placement is performed after full muco-periosteal flap elevation. In conjunction with implant placement a GBR procedure, using autogenous bone (harvested locally) and bovine bone mineral, is performed to overcontour the ridge at the implant site before the flap is coronally advanced and tension-free closure is achieved.

Studies48,70,71 have shown the prevalence for mucosal recession was lower in comparison to some of the studies mentioned earlier in which a Type 1 implant placement protocol was used. Moreover, radiographic evidence derived from CBCTs have shown that the outcome of the GBR procedure was maintained and stable over time.72,73

Conclusions on Immediate Implant PlacementImmediate implants represent a viable treatment modality. However, it is technique sensitive and requires a careful case selection and risk factor analysis to avoid suboptimal treatment outcomes.

The following conditions should be met for immediate implant placement:

1) An intact socket is present following extraction.

2) A thick periodontal phenotype is present.

3) Bone is available on the palatal and apical aspects of the extracted tooth to ensure primary stability.

Technique for Immediate Implant PlacementPrior to the surgery a 3 dimensional radiographic image is helpful to determine the amount of bone available outside of the confine of the socket to predetermine the ability of the surgeon to engage native bone and obtain implant primary stability (Figure 2).

Following local anesthesia, the hopeless tooth must be carefully extracted with the least traumatic technique in order to maintain the integrity of the extraction socket walls; especially the buccal wall. Periotomes are preferred over conventional elevators to decrease the amount of trauma to the bone. Once the tooth has been successfully extracted (Figure 3), careful clinical inspection of the socket must confirmed its integrity. In case, a dehiscence or a fracture of the buccal plate is present, implant placement should be aborted and ridge preservation/augmentation should be performed.

If all the socket walls are intact, the implant bed preparation should start with the first drill (sometimes also called precision drill), which should be a fine, sharp and pointy drill (Figure 4). This first drill allows for repositioning the implant bed irrespective of the walls of the socket in the sagittal (oro-labial angulation, Figure 5) and in the frontal (mesio-distal angulation, Figure 6) planes.

The technical difficulty of preparing an implant bed in a freshly extracted site is the natural propensity of any implant drill to follow the path of the socket. In order to adequately place the implant in a correct

The sagittal cross section of the CBCT demonstrates that the root of tooth #9 is against the labial plate. Native bone is available beyond the apex of the tooth and on the palatal aspect of the root, which will allow implant primary stability. The presence of an intact buccal plate is also observed with no signs of dehiscence.

Figure 2

Intact extraction socket at site #9 following debridement.

Figure 3

Different precision drills commercially available.

Figure 4

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Precision drilled in the frontal view. Notice that not only does the precision drill reposition the implant bed towards the palate (as illustrated on the previous figure) but also in the frontal plane, the mesio-distal angulation is corrected.

Figure 6

Planning of the implant placement based on the sagittal cross section of the CBCT. Notice the palatal position of the implant.

Figure 5

Desired implant position on the sagittal cross section of the CBCT, leaving 2 mm between the shoulder of the implant and the internal wall of the socket.

Figure 7

Post-operative radiographic control.

Figure 10

The horizontal gap between the implant and the socket is grafted with FDBA.

Figure 9

Clinical view of the immediate implant #9 placed in the correct oro-labial and mesio-distal position.

Figure 8

restoratively driven position, the implant bed must be displaced in relation to the socket. For example, in the anterior maxilla, the implant must be placed palatally in relation to the socket not only to fulfill the requirement from a restorative point of view but also to be able to follow the guidelines by Chen and co-workers mentioned above, which require the implant shoulder to be placed approximately 2mm palatally to the point of emergence at adjacent teeth (Figure 7).

While correcting the implant bed preparation is possible with subsequent drills of increasing diameter, the initial drilling with the precision drill should be carefully executed in order to set the

position, axis and angulation of the implant bed in an optimal way. This in turn, allows a much easier implant bed preparation with subsequent drills.

Once the precision drill has enabled the ideal positioning of the implant bed, the use of drills of increasing diameter allow the completion of the osteotomy prior to implant placement in the correct restorative position (Figure 8).

The horizontal defect between the shoulder of the implant and the internal wall of the socket is grafted using, in the illustrated case, a freezed dried mineralized bone allograft (FDBA) (Figure 9). A resorbable collagen membrane is then placed over

the GBR site and the implant. A periosteal releasing incision may be necessary to advance the flap coronally and allow a closer approximation of the edges of the flap before the flap is sutured together and control radiograph is taken (Figure 10).

Post-operative care typically includes the prescription of systemic antibiotics for 7 to 10 days, analgesics and rinsing with a 0.12% Chlorhexidine solution twice a day for 7 to 14 days.

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1. Branemark PI, Hansson BO, Adell R, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scandinavian journal of plastic and reconstructive surgery Supplementum 1977;16:1-132.

2. Esposito M, Grusovin MG, Willings M, Coulthard P, Worthington HV. The effectiveness of immediate, early, and conventional loading of dental implants: a Cochrane systematic review of randomized controlled clinical trials. The International journal of oral & maxillofacial implants 2007;22:893-904.

3. Hammerle CH, Chen ST, Wilson TG, Jr. Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. The International journal of oral & maxillofacial implants 2004;19 Suppl:26-28.

4. Cangini F, Cornelini R. A comparison between enamel matrix derivative and a bioabsorbable membrane to enhance healing around transmucosal immediate post-extraction implants. Journal of periodontology 2005;76:1785-1792.

5. Covani U, Marconcini S, Galassini G, Cornelini R, Santini S, Barone A. Connective tissue graft used as a biologic barrier to cover an immediate implant. Journal of periodontology 2007;78:1644-1649.

6. Fugazzotto PA. Implant placement at the time of maxillary molar extraction: technique and report of preliminary results of 83 sites. Journal of periodontology 2006;77:302-309.

7. Huys LW. Replacement therapy and the immediate post-extraction dental implant. Implant dentistry 2001;10:93-102.

8. Lang NP, Bragger U, Hammerle CH, Sutter F. Immediate transmucosal implants using the principle of guided tissue regeneration. I. Rationale, clinical procedures and 30-month results. Clinical oral implants research 1994;5:154-163.

9. 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. Clinical oral implants research 2012;23 Suppl 5:39-66.

10. Malchiodi L, Cucchi A, Ghensi P, Nocini PF. Evaluation of the esthetic results of 64 nonfunctional immediately loaded postextraction implants in the maxilla: correlation between interproximal alveolar crest and soft tissues at 3 years of follow-up. Clinical implant dentistry and related research 2013;15:130-142.

11. Pecora G, Andreana S, Covani U, De Leonardis D, Schifferle RE. New directions in surgical endodontics; immediate implantation into an extraction site. Journal of endodontics 1996;22:135-139.

12. Romeo E, Lops D, Rossi A, Storelli S, Rozza R, Chiapasco M. Surgical and prosthetic management of interproximal region with single-implant restorations: 1-year prospective study. Journal of periodontology 2008;79:1048-1055.

13. Degidi M, Piattelli A, Carinci F. Immediate loaded dental implants: comparison between fixtures inserted in postextractive and healed bone sites. The Journal of craniofacial surgery 2007;18:965-971.

14. Fugazzotto PA, Lightfoot WS, Jaffin R, Kumar A. Implant placement with or without simultaneous tooth extraction in patients taking oral bisphosphonates: postoperative healing, early follow-up, and the incidence of complications in two private practices. Journal of periodontology 2007;78:1664-1669.

15. Norton MR. A short-term clinical evaluation of immediately restored maxillary TiOblast single-tooth implants. The International journal of oral & maxillofacial implants 2004;19:274-281.

16. Rodrigo D, Martin C, Sanz M. Biological complications and peri-implant clinical and radiographic changes at immediately placed dental implants. A prospective 5-year cohort study. Clinical oral implants research 2012;23:1224-1231.

17. Chen ST, Darby IB, Reynolds EC. A prospective clinical study of non-submerged immediate implants: clinical outcomes and esthetic results. Clinical oral implants research 2007;18:552-562.

18. 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. The International journal of periodontics & restorative dentistry 2005;25:439-447.

19. Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clinical oral implants research 2008;19:73-80.

20. Grunder U. Stability of the mucosal topography around single-tooth implants and adjacent teeth: 1-year results. The International journal of periodontics & restorative dentistry 2000;20:11-17.

21. Juodzbalys G, Wang HL. Soft and hard tissue assessment of immediate implant placement: a case series. Clinical oral implants research 2007;18:237-243.

22. Kan JY, Rungcharassaeng K, Sclar A, Lozada JL. Effects of the facial osseous defect morphology on gingival dynamics after immediate tooth replacement and guided bone regeneration: 1-year results. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2007;65:13-19.

23. Lindeboom JA, Frenken JW, Dubois L, Frank M, Abbink I, Kroon FH. Immediate loading versus immediate provisionalization of maxillary single-tooth replacements: a prospective randomized study with BioComp implants. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2006;64:936-942.

24. Palattella P, Torsello F, Cordaro L. Two-year prospective clinical comparison of immediate replacement vs. immediate restoration of single tooth in the esthetic zone. Clinical oral implants research 2008;19:1148-1153.

25. Wagenberg B, Froum SJ. A retrospective study of 1925 consecutively placed immediate implants from 1988 to 2004. The International journal of oral & maxillofacial implants 2006;21:71-80.

26. Wohrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: fourteen consecutive case reports. Practical periodontics and aesthetic dentistry : PPAD 1998;10:1107-1114; quiz 1116.

27. Kokich VO, Kokich VG, Kiyak HA. Perceptions of dental professionals and laypersons to altered dental esthetics: asymmetric and symmetric situations. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics 2006;130:141-151.

28. Chen ST, Darby IB, Adams GG, Reynolds EC. A prospective clinical study of bone augmentation techniques at immediate implants. Clinical oral implants research 2005;16:176-184.

29. Lindeboom JA, Tjiook Y, Kroon FH. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics 2006;101:705-710.

30. Ochsenbein C, Ross S. A reevaluation of osseous surgery. Dental clinics of North America 1969;13:87-102.

31. Morton D, Chen ST, Martin WC, Levine RA, Buser D. Consensus statements and recommended clinical procedures regarding optimizing esthetic outcomes in implant dentistry. The International journal of oral & maxillofacial implants 2014;29 Suppl:216-220.

32. Braut V, Bornstein MM, Belser U, Buser D. Thickness of the anterior maxillary facial bone wall-a retrospective radiographic study using cone beam computed tomography. The International journal of periodontics & restorative dentistry 2011;31:125-131.

33. Huynh-Ba G, Pjetursson BE, Sanz M, et al. Analysis of the socket bone wall dimensions in the upper maxilla in relation to immediate implant placement. Clinical oral implants research 2010;21:37-42.

34. Januario AL, Duarte WR, Barriviera M, Mesti JC, Araujo MG, Lindhe J. Dimension of the facial bone wall in the anterior maxilla: a cone-beam computed tomography study. Clinical oral implants research 2011;22:1168-1171.

35. Vera C, De Kok IJ, Reinhold D, et al. Evaluation of buccal alveolar bone dimension of maxillary anterior and premolar teeth: a cone beam computed tomography investigation. The International journal of oral & maxillofacial implants 2012;27:1514-1519.

36. Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. Journal of clinical periodontology 2005;32:212-218.

37. Ferrus J, Cecchinato D, Pjetursson EB, Lang NP, Sanz M, Lindhe J. Factors influencing ridge alterations following immediate implant placement into extraction sockets. Clinical oral implants research 2010;21:22-29.

References

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38. Matarasso S, Salvi GE, Iorio Siciliano V, Cafiero C, Blasi A, Lang NP. Dimensional ridge alterations following immediate implant placement in molar extraction sites: a six-month prospective cohort study with surgical re-entry. Clinical oral implants research 2009;20:1092-1098.

39. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. The International journal of periodontics & restorative dentistry 2006;26:19-29.

40. Pietrokovski J, Starinsky R, Arensburg B, Kaffe I. Morphologic characteristics of bony edentulous jaws. Journal of prosthodontics : official journal of the American College of Prosthodontists 2007;16:141-147.

41. Tan WL, Wong TL, Wong MC, Lang NP. A systematic review of post-extractional alveolar hard and soft tissue dimensional changes in humans. Clinical oral implants research 2012;23 Suppl 5:1-21.

42. Tomasi C, Sanz M, Cecchinato D, et al. Bone dimensional variations at implants placed in fresh extraction sockets: a multilevel multivariate analysis. Clinical oral implants research 2010;21:30-36.

43. Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Tissue modeling following implant placement in fresh extraction sockets. Clinical oral implants research 2006;17:615-624.

44. Araujo MG, Wennstrom JL, Lindhe J. Modeling of the buccal and lingual bone walls of fresh extraction sites following implant installation. Clinical oral implants research 2006;17:606-614.

45. Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. Journal of clinical periodontology 2004;31:820-828.

46. Botticelli D, Renzi A, Lindhe J, Berglundh T. Implants in fresh extraction sockets: a prospective 5-year follow-up clinical study. Clinical oral implants research 2008;19:1226-1232.

47. Bonfante EA, Janal MN, Granato R, et al. Buccal and lingual bone level alterations after immediate implantation of four implant surfaces: a study in dogs. Clinical oral implants research 2013;24:1375-1380.

48. Chen ST, Buser D. Esthetic outcomes following immediate and early implant placement in the anterior maxilla--a systematic review. The International journal of oral & maxillofacial implants 2014;29 Suppl:186-215.

49. 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. Clinical oral implants research 2017;28:902-910.

50. DeGroot BS, Villar CC, Mealey BL, Mills MP, Prihoda TJ, Huynh-Ba G. Osseous Healing Around Immediate Implants Placed Using Contour Augmentation: A Prospective Case Series. The International journal of periodontics & restorative dentistry 2017;37:883-891.

51. Poulias E, Greenwell H, Hill M, et al. Ridge preservation comparing socket allograft alone to socket allograft plus facial overlay xenograft: a clinical and histologic study in humans. Journal of periodontology 2013;84:1567-1575.

52. Cosyn J, Sabzevar MM, De Bruyn H. Predictors of inter-proximal and midfacial recession following single implant treatment in the anterior maxilla: a multivariate analysis. Journal of clinical periodontology 2012;39:895-903.

53. Peng M, Fei W, Hosseini M, Gotfredsen K. Influence of implant position on clinical crown length and peri-implant soft tissue dimensions at implant-supported single crowns replacing maxillary central incisors. The International journal of periodontics & restorative dentistry 2013;33:785-793.

54. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. The International journal of oral & maxillofacial implants 2004;19 Suppl:43-61.

55. Jansen CE, Weisgold A. Presurgical treatment planning for the anterior single-tooth implant restoration. Compendium of continuing education in dentistry (Jamesburg, NJ : 1995) 1995;16:746, 748-752, 754 passim; quiz 764.

56. Weisgold AS. Contours of the full crown restoration. The Alpha omegan 1977;70:77-89.

57. Baldi C, Pini-Prato G, Pagliaro U, et al. Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. Journal of periodontology 1999;70:1077-1084.

58. 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. The International journal of oral & maxillofacial implants 2011;26:179-187.

59. Kois JC. Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compendium of continuing education in dentistry (Jamesburg, NJ : 1995) 2004;25:895-896, 898, 900 passim; quiz 906-897.

60. Cook DR, Mealey BL, Verrett RG, et al. Relationship between clinical periodontal biotype and labial plate thickness: an in vivo study. The International journal of periodontics & restorative dentistry 2011;31:345-354.

61. Fu JH, Yeh CY, Chan HL, Tatarakis N, Leong DJ, Wang HL. Tissue biotype and its relation to the underlying bone morphology. Journal of periodontology 2010;81:569-574.

62. Burkhardt R, Joss A, Lang NP. Soft tissue dehiscence coverage around endosseous implants: a prospective cohort study. Clinical oral implants research 2008;19:451-457.

63. Levine RA, Huynh-Ba G, Cochran DL. Soft tissue augmentation procedures for mucogingival defects in esthetic sites. The International journal of oral & maxillofacial implants 2014;29 Suppl:155-185.

64. Kan JY, Roe P, Rungcharassaeng K, et al. Classification of sagittal root position in relation to the anterior maxillary osseous housing for immediate implant placement: a cone beam computed tomography study. The International journal of oral & maxillofacial implants 2011;26:873-876.

65. Jung RE, Zaugg B, Philipp AO, Truninger TC, Siegenthaler DW, Hammerle CH. A prospective, controlled clinical trial evaluating the clinical radiological and aesthetic outcome after 5 years of immediately placed implants in sockets exhibiting periapical pathology. Clinical oral implants research 2013;24:839-846.

66. Siegenthaler DW, Jung RE, Holderegger C, Roos M, Hammerle CH. Replacement of teeth exhibiting periapical pathology by immediate implants: a prospective, controlled clinical trial. Clinical oral implants research 2007;18:727-737.

67. Esposito M, Maghaireh H, Grusovin MG, Ziounas I, Worthington HV. Soft tissue management for dental implants: what are the most effective techniques? A Cochrane systematic review. European journal of oral implantology 2012;5:221-238.

68. Lee CT, Tao CY, Stoupel J. The Effect of Subepithelial Connective Tissue Graft Placement on Esthetic Outcomes After Immediate Implant Placement: Systematic Review. Journal of periodontology 2016;87:156-167.

69. Buser D, Chen ST, Weber HP, Belser UC. Early implant placement following single-tooth extraction in the esthetic zone: biologic rationale and surgical procedures. The International journal of periodontics & restorative dentistry 2008;28:441-451.

70. Buser D, Wittneben J, Bornstein MM, Grutter L, Chappuis V, Belser UC. Stability of contour augmentation and esthetic outcomes of implant-supported single crowns in the esthetic zone: 3-year results of a prospective study with early implant placement postextraction. Journal of periodontology 2011;82:342-349.

71. Miyamoto Y, Obama T. Dental cone beam computed tomography analyses of postoperative labial bone thickness in maxillary anterior implants: comparing immediate and delayed implant placement. The International journal of periodontics & restorative dentistry 2011;31:215-225.

72. Buser D, Chappuis V, Bornstein MM, Wittneben JG, Frei M, Belser UC. Long-term stability of contour augmentation with early implant placement following single tooth extraction in the esthetic zone: a prospective, cross-sectional study in 41 patients with a 5- to 9-year follow-up. Journal of periodontology 2013;84:1517-1527.

73. Chappuis V, Rahman L, Buser R, Janner SFM, Belser UC, Buser D. Effectiveness of Contour Augmentation with Guided Bone Regeneration: 10-Year Results. J Dent Res 2017: [Epub ahead of print].

References (continued)

Quality Resource Guide l Immediate Dental Implants 2nd Edition 8

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POST-TESTInternet Users: This page is intended to assist you in fast and accurate testing when completing the “Online Exam.” We suggest reviewing the questions and then circling your answers on this page prior to completing the online exam. (1.0 CE Credit Contact Hour) Please circle the correct answer. 70% equals passing grade.

1. Which of the following timing of implant placement, as defined by the ITI (International Team for Implantology), represents the most conservative approach, in which the dental implant is placed after complete healing of the extraction site (with ridge preservation)?a. Type 1 implant placementb. Type 2 implant placementc. Type 3 implant placementd. Type 4 implant placement

2. Which of the following statements about immediate implants is (are) correct:a. Immediate implants are technique sensitive.b. Immediate implants have a similar survival rate as implants placed in

healed sitec. Immediate implants require a careful case selectiond. All of the above

3. According to the literature, what is the prevalence of mucosal facial recession following immediate implant placement?a. Less than 1% of the casesb. Less than 5% of the casesc. Between 8% and 40% of the casesd. More than 50% of the cases

4. The utmost important risk factor related to peri-implant mid-facial soft tissue recession is:a. The presence of a thick phenotypeb. Implant placed too far faciallyc. A thin (<1mm) bony palatal walld. The inability to achieve primary stability

5. If the buccal plate integrity has been lost following tooth extraction, what is the recommended procedure?a. Let the extraction site heal by itself for 3 months before implant

placement.b. Use a staged approach including ridge augmentation first and

implant placement after the ridge has healed.c. Proceed with immediate implant placement without any

accommodation.d. Proceed with immediate implant placement with systemic antibiotic.

6. When placing an immediate implant in an extraction socket at what distance should the shoulder of the implant be in relation to the internal border of the buccal bone wall?a. 0.5 mmb. 1 mmc. 1.5 mmd. 2 mm

7. Recession coverage of an implant can be attempted by means of a connective tissue graft. Concerning this technique, which of the following statement is FALSE?a. The patient needs to have a good plaque control.b. The result of this procedure is more predictable around teeth (with

Class 1 Miller recession).c. You will get complete long term recession coverage in a predictable

way.d. The site cannot present deep probing pocket depth.

8. Type 2 implant placement has been suggested as a treatment alternative to type 1. Following this protocol, how many weeks following extraction is the implant placed?a. 1 to 2 weeksb. 2 to 4 weeksc. 4 to 8 weeksd. 8 to 12 weeks

9. All the followings apply to a precision drill EXCEPT:a. It pinpoints the entrance of the osteotomy site.b. It widens the implant bed preparation right before implant insertion.c. It is thin and pointy.d. It defines the osteotomy pathway irrespective of the extraction socket

walls.

10. Post-operative care typically includes:a. Systemic antibiotics for 7 to 10 daysb. Methyl-prednisolonec. Analgesics and 0.12% Chlorhexidine rinsed. All of the above

9

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