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Journal of Oral Rehabilitation 2008 35 (Suppl. 1); 33–43
Timing of implant placement relative to tooth extraction
L. SCHROPP & F. ISIDOR
Department of Prosthetic Dentistry, University of Aarhus, Aarhus C, Denmark
In recent years, immediate or early implant placement after tooth extraction has becoming more common. The present review focuses on
the clinical outcome of immediate or early implant
placement. Only limited knowledge exists about
most of the factors with particular significance for
this treatment mode. Randomized controlled clinical studies comparing the various treatment protocols are scarce. With the background in the existing
literature some conclusions can be drawn with
caution. Survival rates for implants placed immediately, early, delayed, or late seem to be similar in the
short perspective and amounts to approximately
95%. Successful immediate implant placement may
be possible in all regions of the jaws, although
replacement of molars is more challenging. Chronic
infection is not an absolute contraindication for
immediate implant placement. It is controversial
whether immediate placement of implants may
preserve the alveolar bone. Small gaps between
SUMMARY
Introduction
Placement of dental implants for replacing missing teeth
is a well-established treatment option. According to the
original protocol, it was state of the art to wait several
months after tooth extraction before placement of the
implants to allow alveolar bone healing (1). Along with
the recommended load-free period of 3–6 months to
ensure osseointegration of the implants, a long treatment period was an obvious drawback of this treatment
modality. This protocol has been challenged the last
decades by reducing the time between extraction of a
tooth and placing and ⁄ or loading of the implant.
Various classifications have been suggested for the
timing between tooth extraction and implant placement. This can make it difficult to compare the outcome
of previous studies. In a recent systematic review, an
implant surface and socket wall have a potential
for spontaneous healing. No consensus exists on the
need for bone augmentation in these situations.
With the limited information available it may be
stated that a good prognosis can be obtained following immediate ⁄ early functional or non-functional loading of immediately placed implants.
However, higher risk of failures seems to exist
compared with a delayed, conventional approach.
It is advocated that this treatment modality should
be restricted to skilled well-trained teams. Data on
the aesthetic outcomes following immediate ⁄ early
implant placement are inconclusive, but this treatment can offer high patient satisfaction with the
aesthetic and functional outcomes.
KEYWORDS: review, timing, implants, placement,
immediate, early, delayed, extraction socket, survival, success
Accepted for publication 4 November 2007
implant placed in a fresh extraction socket was denoted
an immediate implant. An implant placed in an
extraction socket within 8 weeks after tooth extraction
was called immediate-delayed and later placed implants
were called delayed implants (2).
Apart from reducing the time period and the number
of surgical interventions, other advantages of immediate
or early (immediate-delayed) implant placement in the
extraction socket has been suggested, such as better
implant survival rates, better aesthetics, maintenance of
the hard and soft tissues at the extraction site, and
higher patient satisfaction compared with delayed (late)
placed implants. On the other hand, because of the
nature of this treatment method, a higher risk of
complications and failures may be expected.
In 2006, Esposito et al. (2) published a systematic
review of randomized controlled trials (RCT) on dental
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
doi: 10.1111/j.1365-2842.2007.01827.x
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L. SCHROPP & F. ISIDOR
implants placed in fresh extraction sockets. On the basis
of only two studies fulfilling the selection criteria, it was
concluded that immediate or immediate-delayed placement of implants is a viable treatment option and may
be associated with better outcomes in terms of aesthetics and patient satisfaction compared with conventionally placed implants (3–7). The authors, however,
emphasized that more RCT are needed to draw definitive conclusions.
This review will focus on the clinical outcome of
immediate or early implant placement on the basis of
the current literature and point out factors, which may
have especial significance when an implant is placed in
a fresh or recent extraction socket and, therefore,
should be considered by the clinician in patient selection and choice of surgical and prosthetic procedures.
Materials and methods
comparable with those of implants placed in healed
alveolar bone (2, 8–12). In general, approximately 5%
of implants can be expected to be lost regardless the
protocol being used. It should be stressed that the
follow-up period for most of the studies on immediate
implants is relatively short with only few papers
reporting results of >5 years of loading.
Quirynen et al. (12) found that useful data on crestal
bone loss (CBL) is lacking. Most studies only report on
the mean peri-implant bone loss and the authors draw
attention to the fact that frequency distribution on
ranges of marginal bone loss would be more useful
information for the clinician. It was stated that the
above also applies for data on pocket depth and
attachment level changes. Chen et al. (8) concluded in
a review that no significant differences in radiographic
crestal bone level or in probing depth at implants placed
immediately, delayed, or late relative to tooth extraction were found.
Search strategy
A PubMed search of English literature was conducted
up to May 2007 using the terms: implants and
(‘immediate placement’ or ‘delayed placement’ or
‘early placement’ or ‘delayed-immediate’ or ‘extraction
sockets’), ‘immediate extraction sockets’, ‘immediate
post-extraction’, ‘immediate implants’. Additionally,
the bibliographies of 13 previous reviews as well as
articles published in 2007 for nine journals (Clinical Oral
Implants Research, Clinical Implant Dentistry and Related
Research, Implant Dentistry, International Journal of Oral
and Maxillofacial Implants, International Journal of Periodontics and Restorative Dentistry, International Journal of
Prosthodontics, Journal of Periodontics, Journal of Oral
Implantology, Journal of Clinical Periodontology) were
manually searched. This search failed to reveal more
randomized studies than in the review of Esposito et al.
(2). In consequence, a more narrative mode of review
was chosen. The selection criteria were less rigorous as
randomized or non-randomized clinical prospective
and retrospective studies enrolling at least 10 implants
placed in human subjects were included.
Results
The overall outcome of immediate or early implant placement
Reviews of the literature show that the survival rates of
immediately, early, or delayed placed implants are
Benefits and risk factors associated with the immediate
implant placement protocol
Particular conditions exist when an implant is placed in
a fresh or recent extraction alveolus compared with
placement in healed bone. These can be advantageous
to the treatment outcome but may also constitute risk
factors. These aspects will be discussed in the following.
Does immediate implant placement preserve the post-extraction alveolar bone? A prerequisite for success of intraosseous implant treatment is achievement of
osseointegration (13). Furthermore, it has been shown
that primary implant stability is crucial for successful
osseointegration (14). To ensure primary implant stability a sufficient amount of bone of good quality is
needed.
Following extraction of one or more teeth, a significant reduction in vertical height and buccolingual
width of the alveolar ridge takes place. The amount of
the morphological changes is dependent on several
patient related factors and a great variation among
individuals is seen. In a recent study (15), including 46
molar or premolar extraction sites, it was demonstrated
that minor vertical changes occurred following singletooth extraction while the buccolingual width of the
ridge was reduced by approximately 50% during an
observation period of 1 year. In the literature, it has
often been stated that one of the rationales of imme-
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TIMING OF IMPLANT PLACEMENT TO TOOTH EXTRACTION
diate implant placement is that this approach may
prevent or at least minimize the loss of soft and hard
tissue at the extraction site. It is clear that controversies
exist on this issue. A long-term study by Denissen and
Kalk (16) showed that immediately placed submerged
hydroxyapatite implants contributed to the maintenance of alveolar ridge volume, and in addition
Wheeler et al. (17) demonstrated in a clinical report
preservation of hard and soft tissue with enhancement
of the aesthetic result after immediate placement of
tapered root-analog implants combined with custom
healing abutments. On contrary, recent animal and
clinical studies indicate that morphologic changes of the
alveolar ridge cannot be prevented by the immediate
placement protocol (18–23). It was shown that the
buccal and lingual socket walls underwent marked
resorption following implant placement and that the
height of the buccal hard tissue wall was reduced (18).
It is apparently of importance that the immediate
implant is placed correctly in the alveolus to prevent
exposure of the implant surface. It has been suggested
(12) to place the implant lingually ⁄ palatally in the
socket, even though this at first may result in a larger
gap buccally, as bone formation in the defect can be
expected concurrently with resorption of the buccal
bone wall.
Although conflicting results exist, immediate implantation may preserve the post-extraction alveolar bone.
No matter whether the implant is placed immediately
or later in the alveolar bone, it is very important to
extract teeth carefully to minimize bone loss. Particularly, the buccal wall of the alveolus is exposed to
trauma, and damage should be avoided. Sectioning of
multi-rooted teeth is recommended before removal.
Does infection at the extraction site affect the outcome of
immediate implant placement? Pathology of the tooth or
the periodontal tissues may have an influence on the
treatment success when replacing the tooth immediately after removal with an implant. Infection at the
recipient site has been a matter of concern in conjunction with implant placement in the extraction alveolus
and has of some authors been considered as a contraindication for using this protocol. Infection could be
caused by marginal periodontitis, periapical pathology,
failures of endodontic treatments and root fractures. In
addition, loss of tissue because of disease may compromise the possibility of achieving primary implant
stability, as well as impair the aesthetics.
One RCT (3) has been published comparing in sites
with periapical infection, 25 single implants placed
immediately after tooth extraction and 25 implants
placed after 3 months of healing. Two immediate
implants were lost, but no statistically differences in
failure rates, mean Implant Stability Quotient (ISQ)
values, gingival aesthetics, radiographic bone resorption
and periapical microbiologic characteristics were seen
between the groups. The authors concluded that
immediate implant placement in chronic periapical
lesions may be indicated. Two animal studies demonstrated that implants placed in infected sites were not at
risk (24, 25), whereas the success of immediate
implants replacing teeth with a history of marginal
periodontitis was slightly lower in humans (26, 27).
More studies are needed to elucidate the complex of
problems associated with residual infection at the
implant recipient site.
Therefore, on basis of the existing information, it is
not valid to recommend or caution not to do immediate
implant placement in an extraction site with inflammation. On contrary, it seems reasonable to recommend thorough debridement of the chronically infected
extraction socket before implant placement. Furthermore, it seems sensible to use antibiotics in medically
compromised patients. As the use of antibiotics may
have some adverse effects, such as emergence and
accumulation of bacterial drug resistance and various
other side effects, it is important to restrict the use in
cases where necessary.
Does a gap between the implant and the socket wall affect the
outcome of immediate implant placement? When an implant is placed in a fresh or recent extraction alveolus a
gap between the implant surface and the bone walls of
the socket may occur. The presence or size of the gap is
both influenced by the configuration of the alveolus
and by the design and width of the implant. The socket
configuration is mainly determined by the anatomy of
the extracted tooth; however, pathology of the tooth or
in its vicinity before extraction, as well as trauma in
relation to removal of the tooth may cause damage to
the bone walls. This may in turn alter the original
anatomy and in severe cases leave the socket in absence
of one or more bone walls with formation of a
dehiscence defect.
It has been a matter of debate whether such gaps or
dehiscence defects necessitated performance of bone
augmentation procedures or whether they could be left
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
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L. SCHROPP & F. ISIDOR
for spontaneous healing. Studies have demonstrated
that infrabony defects were fully or partly resolved
without intervention of augmentation treatments. In
46 patients treated with immediate implants total bone
formation occurred in the sockets without the use of
membranes or bone grafting (26). In a randomized
study comparing immediate and delayed implant placement a high potential for spontaneous healing in threewall infrabony defects was demonstrated for both
protocols (4). In an animal study, it was shown that a
circumferential gap of 1–1Æ25 mm lateral to an implant
may heal with new bone and that placement of a
membrane did not improve the healing (28). In a RCT
(29) comparing maxillary single implants placed in
extraction sockets in patients treated with particulated
autogenous bone with patients not subjected to any
augmentation procedure, substantial bone gain was
obtained in both groups, and no statistically significant
differences were found.
In the case that immediate placement results in a
fenestrated implant or a dehiscence defect, the surgeon
must decide whether additional bone augmentation
procedures should be conducted or, alternatively,
whether a delayed approach would be a better choice.
Studies have demonstrated that the potential for spontaneous bone formation at such defects is poor (4, 30).
It has also been shown that predictable augmentation of
dehisced sites associated with immediate implants is
possible using resorbable ⁄ non-resorbable membranes
alone or in combination with autogenous bone grafts ⁄
bone substitutes (8, 11). However, it is worth noticing
that bone augmentation procedures on the other hand
may also compromise the treatment outcome. Complications related to bone grafting and early membrane
exposure has been described (31, 32). One of the
challenges in relation to implant placement in fresh
extraction sockets is achievement of sufficient primary
wound closure, which otherwise may increase the risk
of exposed membranes and possibly also lead to
impaired aesthetics.
In an attempt to avoid or minimize, the size of gaps
and fenestrations at immediate implants after placement, new implant designs have been developed.
Conical-shaped or tapered implants have shown promising results with failure rates consistent with those
observed for standard implants in healed sites and fresh
or recent extraction sockets (33). However, there are
currently no evidence proving that the tapered implant
design is superior to cylindrical standard-implants (34).
Likewise, wide-diameter implants have been used in
healed bone and in extraction sockets with success (35,
36). One concern of placing wide implants might be
that presence of fragile bone walls or concavities in the
alveolar bone may lead to dehiscences or fenestrations.
There are only few reports on this topic and more
studies are needed to verify the advantages and disadvantages of this type of implants.
It can be concluded, that a gap around the implant
placed immediately in an extraction site has good
potential to heal. With the presence of a dehiscence the
healing potential is poor and it is not known if one
technique might be superior to others for augmenting
bone in such a case.
Should immediately placed implants be submerged in the
healing period? The original implant treatment protocol
recommended that the implant should be covered with
mucosa after placement to ensure osseointegration. The
rationale was partly to protect the implant site from
bacterial contamination, partly to avoid loading of the
implant. Today, the use of non-submerged (transmucosal) implants is a well-established treatment option,
which has proven to perform equal to the submerged
approach. When letting the implant penetrate to the
oral cavity just after placement, two options exist: (i)
mounting of a healing cap or (ii) mounting of a
restoration. The latter option will be discussed in the
following section.
As gaps around the implant frequently are present
after immediate placement and these in some cases
need to be treated with bone grafting or membranes, it
is relevant to question whether transmucosal implants
placed in extraction sockets may be successful. Several
investigations have demonstrated that non-submerged,
immediately placed implants have good results (34, 37–
41). High survival rates and predictable bone generation around transmucosal immediate implants treated
with resorbable or non-resorbable membranes and ⁄ or
bone grafting were found. However, it should be
emphasized that only short-term outcomes were presented.
Is immediate or early restoration ⁄ loading of immediately
placed implants an option? Removal of a tooth will often
have a negative psychological effect on the patient.
Many people would prefer to leave the dental practice
with a replacement for the extracted tooth, particularly
if the anterior region is involved. As the use of an
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TIMING OF IMPLANT PLACEMENT TO TOOTH EXTRACTION
interim removable prosthesis may be inconvenient to
the patient and a provisional resin-bonded fixed prosthesis is difficult for the dentist because of lack of space
when the abutment teeth are not to be prepared, it
would be tempting to restore the implant immediately,
or alternatively soon, after tooth extraction with a
provisional restoration. The implant restoration could
either be immediately ⁄ early functionally or non-functionally loaded (42). Non-functional loading means
that the restoration is out of occlusion. Recent reviews
have reported on the combination of immediate
implant placement and immediate restoration ⁄ loading
(12, 43–45), but their conclusions are in conflict. In one
review (45), it was concluded that the success of
immediate or early loading of implants may not be
compromised by placement in extraction sockets as
long as placement in sites with a history of marginal
periodontitis is avoided, while Quirynen et al. (12)
conclude that the incidence of implant loss is higher
when combining immediate placement and immediate
loading. Ganeles and Wismeijer (44) calculated an
overall success rate of 96Æ4% for eight publications. All
reviews agreed in that achievement of primary implant
stability is a prerequisite for treatment success. Furthermore, it was emphasized that only short- ⁄ mediumterm studies exist. It should also be stressed that
evidence for success in the maxilla as well as the
posterior mandible of immediate loaded implants –
placed in fresh extraction sockets or in healed bone – is
limited. In a recent study (46), 50 implants were placed
in partially edentulous areas in maxillae and posterior
mandibles directly into extraction alveoli, and temporary prostheses were connected immediately after
surgery or within 7 days (‘early function’). None of
the implants failed in the 18-month follow-up period.
Cannizzaro et al. (47) demonstrated high success of 202
implants (53 inserted in fresh extraction sockets) placed
with a flapless technique in fully edentulous maxillae.
All restorations (21 fixed prostheses and 12 overdentures) were functionally loaded the same day of the
surgery and followed for 1 year after loading. Two
patients each lost one implant. In another study (48) 22
teeth (19 in the maxilla, 13 premolars) were replaced
by implants and restored with temporary single crowns
immediately after extraction in 22 patients. No clinical
failures were observed during a period of 12 months.
When interpreting the results of implant loading
protocols, it is important to distinguish between immediate functional loading and immediate restoration, as
the outcome of these two approaches may turn out
differently. Despite the limited information available it
may be stated that a good prognosis has been observed
following immediate ⁄ early functional or non-functional loading of immediately placed implants. A risk
of more implant failures exists where it is difficult to
obtain primary implant stability.
Does the type of restoration on immediately placed implants
affect the outcome? In two recent systematic reviews, it
was concluded that implant survival and success may
not be affected by the type of implant prostheses
employed. Bryant et al. (49) did not find clear evidence
that neither fixed nor removable prosthodontics were
superior to the other for rehabilitation of the completely edentulous jaw, or that splinted or non-splinted
implants supporting overdentures performed better
than the others. In a review on implant treatment of
the partially edentulous patient, statistical significance
was not reached for differences between the outcomes
of single-implant restorations and implant-supported
fixed partial prostheses (50).
A study of Watzek et al. (51) demonstrated equal
results for removable and fixed complete prostheses
supported by immediately, early, or late placed implants in 20 patients. Likewise, several clinical trials
have demonstrated that immediately placed implants
can work excellent as support for complete and partial
removable or fixed prostheses, including single-implant
crowns. However, in studies dealing with different
types of prosthetic restorations data are most often
pooled and very few comparative studies exist. There
seems not to be sufficient evidence to give a clear
statement whether or not the type of restoration on
immediately placed implants affects the outcome.
Does location of the immediately placed implant affect the
outcome? Favourable loading of implants is considered
to be important to prevent complications. When placing
an implant in a fresh alveolus, particularly if immediately exposed to the oral cavity (transmucosal) or
immediately ⁄ early restored, it might be expected that
loading conditions play an even bigger role for treatment success. The magnitude of masticatory forces
applied to teeth or implants varies depending on the
location in the jaws with greater forces in the posterior
regions. If only for that reason, one could imagine that
immediate implant placement would be more challenging for replacement of premolars and molars.
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
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Additionally, extraction of a molar will normally leave a
rather large socket, which may impede achievement of
primary stability and increase the risk of bone defects
around the implant just after placement. Implant
success is also associated with bone quality. The density
of the alveolar bone varies considerable in the different
jaw segments with the highest density normally found
in the anterior mandibular region and the lowest in the
maxillary posterior region. This suggests that implants
replacing molars or premolars in the maxilla may be at
more risk. Finally, anatomical structures, such as the
maxillary sinuses and the mandibular canal, in the
vicinity of the implant recipient site may compromise
the treatment. This is particularly true in relation to
immediate placement because of the fact that the
implant frequently must be placed several millimeters
apically to the bottom of the alveolus in order to
achieve primary stability.
There is no evidence in the literature suggesting that
placement of implants into fresh or recent extraction
sockets should be restricted to certain locations. Several
studies have shown predictable results of immediate
placement of implants after tooth extraction at maxillary or mandibular molar sites (36, 52–57). Survival
rates between 89% and 100% were found with followup periods from 6 months to 5 years. One study (52)
revealed a better prognosis after 5 years for implants in
the mandible (CSR of 92%) compared with the maxilla
(CSR of 82%).
Even though immediate replacement of molars with
implants seems to be a safe method, adverse conditions
at the implant site, e.g. insufficient amount of bone,
poor bone quality, or conflict with adjacent anatomical
structures, may rule out the possibility of following this
protocol in specific cases. Therefore, careful case selection is still an important part of the treatment planning.
Does immediate implant placement affect the aesthetic
results? Improvement of the aesthetics has frequently
been pointed out to be one advantage of immediate or
early implant placement. The rationale is that soft and
hard tissue may be preserved by using this protocol;
however, as discussed elsewhere in this review, this
issue is still of debate. Contradictory conclusions have
been reached in a direct comparison of the aesthetic
outcome following the early and delayed placement
techniques (7, 58). Gotfredsen (58) using a submerged
technique found that delayed placement (12 weeks)
after tooth extraction performed better than early
placement (4 weeks), whereas Schropp et al. (7) concluded that early placement (on average 10 days after
extraction) of single-tooth implants may be preferable
to delayed implant placement technique (12 weeks) in
terms of early generation of interproximal papillae and
the achievement of an appropriate clinical crown
height. On the other hand, at 1Æ5 years after mounting
the crown on the implant no difference in papilla
dimensions was seen between the groups.
Other factors than the timing of implant placement
may be more important for the achievement of optimal
aesthetic results: position and angulation of the
implant, bone and ⁄ or soft tissue grafting, gingival
biotype, implant design, submerged versus non-submerged implants, immediate ⁄ early restorations, and
flapless procedures.
Recently, several articles have been published on
flapless implant surgery. This modified technique has
been applied in cases of implants placed in extraction
sockets as well. High survival rates and satisfactory
aesthetic results were achieved for anterior maxillary
single-tooth implants placed without incisions or flap
elevation (59, 60), and Cannizzaro et al. (47) demonstrated successful outcomes after 1 year for immediately loaded implants placed with flapless surgery in
fully edentulous maxillae. One drawback of placing
implants without raising a flap may be that visual
inspection of the recipient site is markedly reduced.
Furthermore, the access to performing tissue augmenting procedures is very limited. When interpreting the
results of studies dealing with flapless surgery, it is very
important to pay attention to the inclusion and exclusion criteria. In some studies (60, 61) implant sites
showing bone fenestrations, bone dehiscences, or larger
peri-implant infrabony defects were excluded. Immediate placement of an implant may improve the shortterm aesthetic results, but a definitive conclusion
cannot be drawn.
Does immediate implant placement affect patient satisfaction? Success of dental treatment has traditionally been
evaluated from the clinician’s viewpoint. However, the
significant treatment outcomes from the patient’s perspective may differ from those of the dentist. High
comfort, improved aesthetics, better chewing function,
better phonetics are parameters typically considered
being important to the patient, while probing pocket
depths, degree of osseointegration, crestal bone levels,
etc. are of minor significance. Recently, more focus has
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TIMING OF IMPLANT PLACEMENT TO TOOTH EXTRACTION
Table 1. Summary of conclusions and authors’ suggested guidelines for immediate or early implant placement
Conclusions
Literature
Overall outcomes
Survival rates
(SR)
Crestal bone loss
(CBL)
Probing pocket
depth (PPD)
Preservation of
alveolar bone
Infection at the
extraction site
Peri-implant defects
Submerged vs.
transmucosal
implants
Immediate
placement and
immediate
restoration ⁄
loading
Type of restoration
Location of implant
site
Clinical guidelines
A vast number of studies were found. However, only a
few randomized controlled trials (RCT) or long-term
prospective trials exist
SR for immediately, early, delayed, or late placed
implants are equal, amounting to approximately
95% in the short perspective
No statistically significant differences in mean crestal
bone loss between the protocols
No statistically significant differences in mean probing
pocket depth between the protocols
Capability of immediate implants to preserve the
alveolar bone is controversial
Morphologic changes of the post-extraction site may
occur despite immediate ⁄ early implant placement
Damage to the alveolar bone may occur during tooth
extraction
Controversies exist on whether local pathology has an
adverse effect on the outcome
There is no evidence to recommend the use of
antibiotics prophylactically, apart from in medically
compromised patients
A history of marginal periodontitis may endanger
treatment outcome. The explanation might be that
achievement of primary stability is impeded, and ⁄ or
that remaining infection is harmful to
osseointegration
Small gaps between implant surface and socket wall
have a potential for spontaneous healing
GBR and grafting perform successfully for
augmentation of dehiscences and fenestrations;
however, no evidence exists that one technique or
material is superior to others
Complications related to bone grafting and early
membrane exposure has been described
Tapered implants are not superior to cylindrical,
standard implants
No significant differences between the two protocols
Better aesthetics after non-submerged implant
placement has not been convincingly demonstrated
High success of this treatment modality implemented
in the anterior mandible has been found. Limited
data are available for the maxilla and posterior
mandible
Immediately placed implants can work excellent as
support for complete and partial – removable or fixed
– prostheses, including single-implant crowns
Removable and fixed complete prostheses perform
equally well in terms of implant success
Scarce information in the literature
Successful immediate implant placement may be
possible in all regions of the jaws
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
Slightly palatally ⁄ lingually placement of the implant
in the extraction socket to avoid exposure of the
implant surface
Careful extraction is recommendable. Multi-rooted
teeth should be sectioned before removal
Chronic infection is not an absolute contraindication
for immediately placed implants, however, thorough
debridement of the alveolus should be made
The use of antibiotics should mainly be used in
medically compromised patients
One should be more cautious when replacing teeth
lost because of marginal periodontitis with
immediate implants
Bone augmentation procedures should be restricted to
dehiscences, fenestrations and larger infrabony
defects
Possibility of wound closure should be considered
when choosing submerged technique
Immediate loading of immediately placed implants
may be a viable treatment option in the anterior
region of the mandible
Achievement of primary implant stability is a
prerequisite for success
No recommendations for the design of
implant-supported prostheses can be made because
of insufficient evidence
Replacement of molars is more challenging and
careful case selection should be made
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Table 1. (Continued)
Aesthetics
Flapless vs. flap
elevation
Patient satisfaction
Conclusions
Clinical guidelines
Data on the aesthetic outcomes following
immediate ⁄ early implant placement are inconclusive
Implant placement with the flapless mode can offer
successful outcomes. Improved aesthetics of this
technique has not been proven
Immediate ⁄ early implant placement may offer high
patient satisfaction concerning aesthetics and
functional outcomes
Other factors than timing of implant placement should
be considered to obtain favourable aesthetic results
The flapless technique requires careful case selection,
as visual inspection and performance of bone
augmentation procedures are hampered
been put on patient-based outcome measures in the
assessment of dental treatment in general (62, 63).
It has been demonstrated that high patient satisfaction with the aesthetic outcome of implant-supported
single-tooth restorations can be achieved (5, 64–68).
Reduction of treatment time and fewer surgical interventions are advantages of immediate ⁄ early implant
placement. Therefore, this protocol might be expected
to increase patient satisfaction. A study (69) combining
immediate placement and immediate loading of 33
single-implants showed satisfactory aesthetic and functional results from the patients’ viewpoint. In a RCT (5)
comparing early and delayed implant placement overall
satisfaction of the treatment was highest with the early
placed implants, while no significant differences between the groups in patient assessment of shape,
colour, chewing function, and ease of cleaning were
found. It can be concluded that patients treated with
the immediate implant placement protocol are highly
satisfied.
classification, there is obviously a need for uniformity
in this regard.
Conclusions
Based on a review of the current literature, it can be
concluded that immediate or early placement of implants
may be a viable alternative to delayed placement.
However, it is at the same time very important to
emphasize that several clinical parameters have to be
considered if this treatment option shall succeed. Along
with careful case selection, the surgical and prosthetic
protocols must be closely followed. In the authors’
opinion the immediate implant placement procedure is
technique-sensitive and may be more difficult to execute
than the conventional procedure. Therefore, we advocate that this treatment modality should be restricted to
well-trained dental teams. A summary of the conclusions
and suggested guidelines are presented in Table 1.
Conflicts of interest
Classification
Both authors declare no conflicts of interest.
Various terms and classifications have been suggested
for the timing between tooth extraction and implant
placement, which may make it difficult to compare the
outcome of previous studies of the literature. As an
alternative to using a strict indication of time between
the procedures, Hämmerle et al. (70) proposed a new
classification based on soft and hard tissue healing
parameters: (i) Implant placement immediately following tooth extraction and as part of the same surgical
procedure. (ii) Complete soft tissue coverage (typically
4–8 weeks). (iii) Substantial clinical and ⁄ or radiographic bone fill of the socket (typically 12–16 weeks).
(iv) Healed site (typically >16 weeks). This classification
seems appropriate, as it considers variations in subjects’
healing capacity. Irrespective of using one or another
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Correspondence: Dr Lars Schropp, Associate Professor, Department of
Prosthetic Dentistry, University of Aarhus, Vennelyst Boulevard 9,
8000 Aarhus C, Denmark.
E-mail: [email protected]
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