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J Clin Periodontol 2008; 35: 649–657 doi: 10.1111/j.1600-051X.2008.01235.

Immediate single-tooth implants Tim De Rouck1, Kristiaan Collys1 and

Jan Cosyn2,3,4
Departments of 1Restorative Dentistry;

in the anterior maxilla: a 1-year 2

Periodontology, School of Dental Medicine,
Free University of Brussels (VUB), Brussels,
Belgium; 3Department of Periodontology,

case cohort study on hard and soft School of Dental Medicine, University of
Ghent, Gent, Belgium; 4Centre for
Periodontology and Oral Implantology,

tissue response Zottegem, Belgium

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: 649–657. doi: 10.1111/j.1600-051X.2008.01235.x.

Aim: The objective of the present study was to assess implant survival rate, hard and
soft tissue response and aesthetic outcome 1 year after immediate placement and
provisionalization of single-tooth implants in the pre-maxilla. All patients underwent
the same strategy, that is mucoperiosteal flap elevation, immediate implant placement,
insertion of a grafting material between the implant and the socket wall and the
connection of a screw-retained provisional restoration.
Material and Methods: Thirty consecutive patients were treated for single-tooth
replacement in the aesthetic zone by means of immediate implant placement and
provisionalization. Reasons for tooth loss included caries, periodontitis or trauma.
At 6 months, provisional crowns were replaced by the permanent ones. Clinical and
radiographic evaluation was completed at 1, 3, 6 and 12 months to assess implant
survival and complications, hard and soft tissue parameters and patient’s aesthetic
Results: One implant had failed at 1 month of follow-up, resulting in an implant
survival rate of 97%. Radiographic examination yielded 0.98 mm mesial, respectively,
0.78 mm distal bone loss. Midfacial soft tissue recession and mesial/distal papilla
shrinkage were 0.53, 0.41and 0.31 mm, respectively. Patient’s aesthetic satisfaction Key words: dental implants; hard tissue;
immediate implantation; immediate loading;
was 93%. maxilla; single-tooth; soft tissue
Conclusions: The preliminary results suggest that the proposed strategy can be
considered to be a valuable treatment option in well-selected patients. Accepted for publication 18 February 2008

The prosthetic rehabilitation of a single an accepted concept. The original Brå- protocol has been modified by several
maxillary anterior tooth with an nemark protocol suggested 3 months of investigators to include one-stage surgery
implant-supported fixed prosthesis is soft and hard tissue healing following (Becker et al. 1997), immediate post-
tooth removal and an additional 3–6- extraction implant placement (Lazzara
Conflict of interest and source of month load-free osseointegration period 1989, Werbitt & Goldberg 1992, Polizzi
fundings statements (Albrektsson et al. 1981, Branemark et al. 2000) and immediate provisionali-
The authors declare that they have no
1983). This leads to many months of zation (Gomes et al. 1998, Ericsson et al.
conflict of interests. waiting with an uncomfortable remova- 2000). Studies have been published in
The study was supported by the Depart- ble partial denture and several surgical which these three approaches are com-
ment of Restorative Dentistry and Perio- interventions. Based on the aforemen- bined (De Rouck et al. 2007). Most
dontology of the Free University of tioned concerns, patients occasionally of these reports focused, however, on
Brussels (VUB). The authors wish to prefer a traditional, sometimes destruc- implant survival and preservation of
express their gratitude to Nobel Biocare tive, bridge construction. hard tissues, with much less attention to
Belgium for their support in providing In the last decade, Implant Dentistry the soft tissue architecture. Needless to
dental implants. has evolved considerably: the original say, the aesthetic success of a restoration
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650 De Rouck et al.

is determined by the harmony of the hard was reviewed and approved by the and eating, the use of a 0.2% chlorhex-
and soft tissues (Touati 1995, Grunder ethical board. idine mouthwash two times a day for
et al. 1996). One hour pre-operatively, patients 2 weeks and antibiotic therapy for
In this study, single-tooth replace- were advised to start antibiotic and 5 days (Amoxicillin 500 mg three times
ment was performed by means of muco- analgesic therapy (Amoxicillin 500 mg a day). If necessary, analgesic therapy
periosteal flap elevation, immediate and Ibuprofen 600 mg). Oral disinfec- (Ibuprofen 600 mg maximum three
post-extraction implant placement, tion was performed using a 0.2% chlor- times a day) was continued. All surgical
insertion of a grafting material and the hexidine digluconate mouthwash procedures were performed by one and
connection of a screw-retained provi- (Corsodyl, GlaxoSmithKline, Genval, the same surgeon (J. C.).
sional restoration. The rationale of this Belgium).
treatment concept and its outcome on Teeth scheduled for immediate repla-
Fabrication of the provisional restoration
hard and soft tissues following a 1-year cement were systematically removed
study period are discussed in this paper. following minimal mucoperiostal flap Using the implant impression taken at
elevation (Fig. 1a and b). Periotomes the time of surgery, an individualized
were used to extract as atraumatically as screw-retained provisional crown was
Material and Methods possible. Immediate implant placement fabricated in the dental laboratory. In
Patient selection
(Nobelreplace tapered TiUnites, Nobel brief, an engaging titanium temporary
Biocare, Göteborg, Sweden) was per- abutment (Nobel Biocare) served as a
This study included 30 consecutively formed if the labial crest was intact. carrier for an appropriate hollowed den-
treated cases in 30 different patients at Special attention was paid to the correct ture tooth (Fig. 1d). Selection of the
the Dental Clinic of the Free University selection and three-dimensional posi- latter was principally driven by the
in Brussels (VUB). Patients were tioning of the implant. In the orofacial design and colour of the failing tooth.
selected during a screening visit on the dimension, the implant shoulder was Autopolymerizing acrylic resin
basis of inclusion and exclusion criteria. positioned palatal to the point of emer- (Palavits 55 VS, Heraeus Kulzer,
Inclusion criteria were as follows: gence at adjacent teeth. In the mesiodis- Hanau, Germany) was used to bond
tal dimension, a distance of the implant the temporary abutment and the denture
1. At least 18 years old. shoulder to the neighbouring teeth of tooth and for designing the cervical
2. Good oral hygiene. about 2 mm was pursued. In the apico- portion of the restoration. As a model
3. Presence of a single failing tooth in coronal dimension, the implant shoulder of the opponent jaw was available, the
the anterior maxilla (15–25) with was positioned 1 mm subcrestally or provisional restoration was adjusted to
both neighbouring teeth present. about 4 mm below the outline of the clear centric and eccentric contacts
4. Ideal soft tissue contour at the facial peri-implant mucosa (Fig. 1b). In order before polishing procedures. All tem-
aspect of the hopeless tooth in per- to obtain primary implant stability of at porary crowns were fabricated by one
fect harmony with the surrounding least 35 N cm, which was considered to and the same prosthodontist (T. D. R.).
teeth. be a pre-requisite for immediate provi-
5. Normal to thick-flat gingival biotype. sionalization in this study, surgical sites
Connection of the provisional and
6. Adequate bone height apical to were frequently underprepared. Follow- permanent restoration
the alveolus of the failing tooth ing confirmation of the primary stability
(X5 mm) to ensure primary implant using a Torque Controller (Nobel Bio- Approximately 3 h following implant
stability of at least 35 N cm. care), implant impression was made installation, the healing abutment was
(Fig. 1c). The final implant position removed by the prosthodontist and the
Exclusion criteria were as follows: was recorded using radio-opaque and provisional restoration was tightened at
sterile vinylpolysiloxane material (Elite 15 N cm onto the fixture. In order to
1. Systemic diseases. implants medium, Zhermack, Badia avoid contamination, all restorations
2. Smoking (X10 cigarettes a day). Polesine, Italy). After ensuring that no had been provided with 1% chlorhex-
3. Bruxism, lack of posterior occlusion. impression material had remained at the idine digluconate gel at the abutment
4. Non-treated periodontal diseases. surgical site, a cover screw was attached screw level. The clinician made sure
5. Presence of active infection (pus, to the implant and grafting materials that the provisional restoration was
fistula) around the hopeless tooth. (Bio-Osss 0.25 –1 mm, Geistlich Bio- cleared of all contact in centric occlu-
6. Loss of the labial crest after extrac- materials, Wolhusen, Switzerland) sion and during eccentric movements in
tion of the failing tooth. soaked in blood were inserted to fill order to avoid full functional loading of
the void between the implant and the the implant during healing. Avoidance
alveolus. Particles were gently con- of the site while eating for an 8-week
Surgical procedure
densed and applied to the level of the period was recommended. Figure 1e
implant shoulder. All voids were grafted shows an example of a provisional
Following screening, comprehensive irrespective of their width. Finally, the restoration after 3 months of follow-up.
clinical and radiographic examination cover screw was replaced by an appro- After 6 months, the provisional
was performed by two experienced clin- priate healing abutment and the wound restoration was replaced by a permanent
icians (J. C./T. D. R.) and impressions was closed by means of single sutures cemented restoration. Therefore, a stan-
were taken of both jaws for model (Vicryls 5/0, Johnson & Johnson, dard implant impression was made
analysis. Thereupon, a treatment plan St-Stevens-Woluwe, Belgium). Post- using a polyether impression material
was proposed. All patients consented operative instructions included avoid- (Impregum Pentas, 3M ESPE, Seefeld,
to the planned treatment strategy, which ance of the surgical site while brushing Germany) and an open tray impression
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Immediate single-tooth implants 651

coping (Nobel Biocare). Special atten-

tion was paid to an accurate replication
of the soft tissue architecture. A stan-
dard aesthetic titanium abutment
(Esthetic Abutment, Nobel Biocare)
was used to connect the permanent
metal–ceramic restoration. Cementation
was performed using temporary cement
(Temp-Bonds NE, Kerr, Scafati, Italy).
In Fig. 1f, an example of a permanent
restoration after a follow-up period of
1 year is shown.
All prosthetic procedures were con-
ducted by one and the same prosthodon-
tist (T. D. R.) and all permanent
restorations were fabricated in one and
the same dental laboratory (Dental Art,
Zottegem, Belgium).

Implant survival and complications

At each re-assessment, namely after 1,

3, 6 and 12 months of follow-up,
implant survival and complications
were evaluated. The criteria for success-
ful osseointegration according to Smith
& Zarb (1989) were adopted. These
criteria essentially include major bone Fig. 1. (a) Fracture of tooth 12 near the level of the alveolar crest. (b) Minimal mucoper-
loss, radiolucency, mobility, pain, dis- iosteal flap reflection, tooth extraction and restoration-driven implant placement (Nobelre-
comfort and/or neurosensory changes. place tapered TiUnites diameter 4.3 mm–length 16 mm). (c) Connection of a standard
All biologic and prosthodontic compli- impression coping for the open tray impression technique. (d) Autopolymerizing acrylic resin
cations were recorded during the study is used to bond an appropriate hollowed denture tooth (left) and a temporary titanium
period. abutment (right). (e) Labial view of the provisional screw-retained restoration after 3 months
of follow-up. (f) Labial view of the permanent cemented restoration after 1 year. Note some
additional fill of the mesial interdental space between the 3- and the 12-month follow-up visit.
Hard tissue parameters
Soft tissue parameters Before tooth removal and at 1, 3, 6
Immediately following connection of
and 12 months of follow-up, soft tissue
the provisional restoration and after 3, At 1, 3, 6 and 12 months of follow-up, dimensions were measured as follows:
6 and 12 months, a peri-apical radio- the clinical condition of the implant-
graph was taken using the long-cone restoration was recorded by means of
paralleling technique and an X-ray the following parameters: 1. Papilla levels. The levels were
holder (XCP Bite Block, Dentsply recorded by means of an acrylic stent
Rinn, Elgin, IL, USA). An occlusal jig 1. Plaque score. A dichotomous score provided with direction grooves by
(Futars D Fast, Kettenbach Dental, was given (0 5 no visible plaque at two clinicians (Fig. 2). A papilla
Eschenburg, Germany) was used to the soft tissue margin; 1 5 visible level (mesial papilla level–distal
standardize the angulation and position plaque at the soft tissue margin) at papilla level) is defined as the dis-
of the film in relation to the implant and four sites per implant (mesial, mid- tance between the top of the groove
X-ray beam. All radiographs were facial, distal, palatal). and the top of the papilla measured to
scanned (300 dpi) and digitized 2. Probing depth. It was measured to the nearest 0.5 mm using a manual
(SprintScan 35 Plus, Polaroid, Cam- the nearest 0.5 mm at four sites per probe (CP 15 UNC, Hu-Friedys).
bridge, MA, USA). Changes in marginal implant (mesial, midfacial, distal, 2. Midfacial mucosa level. The level of
bone levels at the mesial and the distal palatal) using a manual probe (CP the peri-implant mucosa at the mid-
aspect of the implant were based on the 15 UNC, Hu-Friedys, Chicago, facial aspect of the tooth/restoration
exact distance between three implant USA). was measured using the same acrylic
threads as provided by the implant man- 3. Bleeding on probing. A dichotomous stent provided with a central direc-
ufacturer (Nobel Biocare). The appro- score was given (0 5 no bleeding; tion groove by two clinicians. The
priate software (Vixwin 2000 v1.11, 1 5 bleeding) at four sites per midfacial level is defined as the dis-
Dentsply Gendex, Lake Zurich, Switzer- implant (mesial, midfacial, distal, tance between the top of the groove
land) was used to calculate bone-level palatal). and the first contact with the peri-
changes over time. All radiographs implant mucosa measured to the
were analysed by two clinicians (J. C./ At each of the re-assessments, oral nearest 0.5 mm using a manual probe
T. D. R.). hygiene was reinforced. (CP 15 UNC, Hu-Friedys).
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652 De Rouck et al.

(Nobelreplace tapered TiUnites: dia- complications within this observation

meter 4.3 mm–length 10 mm: two period, one permanent crown had lost
implants; diameter 4.3 mm–length retention at 8 months of follow-up and
13 mm: eight implants; diameter was re-cemented.
4.3 mm–length 16 mm: 14 implants; dia-
meter 5 mm–length 13 mm: two
implants; diameter 5 mm–length Hard tissue parameters
16 mm: four implants) were inserted.
Table 3 shows the changes in the mesial
The bone gap between the alveolus
and distal bone levels at 3, 6 and 12
and the implant platform that was filled
months of follow-up in relation to the
with Bio-Osss particles had an average
Fig. 2. Acrylic stent with three direction time point of connecting the provisional
orofacial dimension of 1.38 mm (range
grooves to determine the outline of the soft restoration. The largest amount of bone
0–4 mm) at the midfacial aspect of the
tissues at the mesial, distal and midfacial loss was observed in the first 3 months:
implant. Table 2 shows the distribution
aspect of the restoration. 0.58 mm mesially and 0.47 mm distally.
of the gap width sorted per tooth type.
Thereafter, diminished loss was
During the 12-month observation per-
Patient’s aesthetic satisfaction observed. After 1 year of function,
iod, one patient was lost to follow-up
radiographic examination yielded
At the end of the study period, patients after 3 months.
0.98 mm mesial bone loss, respectively,
were asked to express their satisfaction 0.78 mm distal bone loss.
with reference to the aesthetic outcome Implant survival and complications
on the basis of a 10 cm visual analogue
scale labelled with ‘‘not at all satisfied’’ At 1-month follow-up, one of the Soft tissue parameters
at the zero point and ‘‘completely satis- implants had failed (tooth location 21;
fied’’ at the right end point. A staff diameter 5 mm–length 16 mm) as pain, In Table 4, the clinical conditions of the
member (I. W.), who was not involved discomfort and implant mobility implant restorations are shown.
in the treatment, was charged with pre- occurred. The reason for this early loss Throughout the study period, plaque
senting the following question: ‘‘How was unclear. Besides this one early scores remained low (o20%). In fact,
would you rate your satisfaction with failure, all implants remained well inte- 82% of the subjects demonstrated pla-
respect to the aesthetic outcome of your grated based on the criteria for success- que scores of maximum 25%. About
treatment?’’ ful osseointegration proposed by Smith half of the sites exhibited bleeding on
& Zarb (1989), resulting in a 97% probing. A trend towards a reduction
cumulative implant survival rate after in probing depth from 3.90 to 3.46 mm
Statistical analysis 1 year of function. With reference to was found. There were no significant
Data analysis was performed using the
patient as the experimental unit. For all
parameters, the mean values per subject Table 1. Tooth types and reasons for failure
and per visit were calculated, if applic- Tooth types Reasons for failure
able. The changes over time of these
variables were examined by means of fracture caries/endodontic periodontal root resorption total
repeated measures one-way analysis of
variance (ANOVA). The level of signifi- Incisors 8 4 5 2 19
Canines 0 1 0 1 2
cance was set at 5%.
Pre-molars 2 4 2 1 9
Total 10 9 7 4 30

From the 32 patients who had been Table 2. Width of the gap between implant and bony wall according to the extracted tooth type
scheduled from May 2005 to June
2006, 30 (14 men, 16 women; mean Tooth types 0–1 mm 1.1–2 mm 2.1–3 mm 3.1–4 mm Total
age of 54 with a range from 24 to 76) Incisors 10 9 0 0 19
were actually treated for single-tooth Canines 1 1 0 0 2
replacement in the aesthetic zone by Pre-molars 3 3 1 2 9
means of immediate implant placement Total 14 13 1 2 30
and provisionalization. Two patients
had to be excluded during surgery as
loss of the labial crest occurred after
Table 3. Changes in marginal bone levels in relation to the time point of connecting the
extraction of the failing tooth. Table 1
provisional restoration
shows the tooth types and reasons for
tooth loss: more than half were incisors Location Month 3 Month 6 Month 12
and the most prevalent reason for failure
Mesial bone level (mm) 0.58  0.41 0.85  0.52 0.98  0.50
was tooth fracture. Thirty screw-type
Distal bone level (mm) 0.47  0.65 0.66  0.70 0.78  0.55
tapered implants with a micro-rough-
ened body and a machined collar Mean  SD.

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Immediate single-tooth implants 653

Table 4. Clinical conditions of implant restorations at different time intervals Based on the short-term results of the
present study, immediate single-tooth
Parameter Month 1 Month 3 Month 6 Month 12
implants in the anterior maxilla may be
Plaque score (%) 17  22 19  21 18  23 17  18 considered to be a successful treatment
Probing depth (mm) 3.90  0.83 3.76  0.67 3.64  0.76 3.46  0.69 strategy with a cumulative implant sur-
Bleeding on probing (%) 54  30 49  19 46  23 41  16 vival rate of 97% after 1 year of func-
Mean  SD.
tion. This result is comparable to other
short-term studies using the same pro-
tocol (X94%) (Hui et al. 2001, Calvo
Table 5. Inter-examiner reproducibility of soft tissue dimensions Guirado et al. 2002, Lorenzoni et al.
2003, Kan et al. 2003a, Cornelini et al.
Parameter Paired samples Pearson’s Identical
t-test correlation scoring (%) 2005, Barone et al. 2006). Studies with
coefficient longer observation periods yielded sur-
vival rates of X93% (Groisman et al.
Papilla levels (mm) NS 0.994 (p40.001) 81 2003, Norton 2004, Tsirlis 2005, Degidi
Midfacial mucosa level (mm) NS 0.995 (p40.001) 86 et al. 2006, Ferrara et al. 2006). Inter-
NS, non-significant. estingly, these survival rates are in line
with data published for implants
inserted according to the standard pro-
Table 6. Changes in soft tissue dimensions in relation to the pre-operative status tocol (X93%) (Goodacre et al. 1999,
Noack et al. 1999, Krennmair et al.
Parameter Month 1 Month 3 Month 6 Month 12
2002, Romeo et al. 2002, Levin et al.
Mesial papilla 0.50  0.73n 0.64  0.76n 0.50  0.75n 0.41  0.71w 2006). Hence, the time span from
level (mm) extraction to implant placement does
Distal papilla 0.33  0.83w 0.50  0.78n 0.41  0.85w 0.31  0.83 not seem to be the pivotal factor in
level (mm) attaining osseointegration. In contrast,
Midfacial mucosa 0.43  0.68 n
0.48  0.80 0.54  0.77 n
0.53  0.76w the macro- and microstructure of the
level (mm)
implant may be more relevant. In this
Highly significant soft tissue loss in comparison to the pre-operative status: p40.005. study, screw-type tapered implants with
Significant soft tissue loss in comparison to the pre-operative status: 0.005op40.05. a micro-roughened body and a
Mean  SD. machined collar were used. This selec-
tion seemed evident as more bone-
to-implant contact is found around
differences in any of the parameters visit, the midfacial soft tissue recession screw-type implants in comparison
over time. was on average 0.53 mm (p 5 0.011). with cylindrical implants (Vandamme
Table 5 indicates high agreement There were no significant changes in et al. 2007) and high primary stability
among both clinicians for recording midfacial soft tissue levels in the differ- can be achieved easily with a tapered
soft tissue dimensions. Identical scoring ent time intervals. implant design (O’Sullivan et al. 2004).
was found in more than 80%. In addition, micro-roughened implants
Table 6 depicts the dimensional have shown significant biomechanical
changes of the soft tissue outline around Patient’s aesthetic satisfaction advantages over machined implants: as
the implant restorations in relation to the Patient’s aesthetic satisfaction, as deter- a result of contact osteogenesis and
status before tooth extraction. The lar- mined by a visual analogue scale, indi- increased bone-to-implant contact, the
gest reductions in papilla height were cated a mean score of 93%, with a range former benefit from rapid bone apposi-
found at 3 months of follow-up, pointing from 82% to 100%. tion and superior anchorage (Cosyn
to a mean loss of 0.64 mm (po0.001) et al. 2007). Finally, we used implants
for mesial papillae and 0.50 mm with a standard machined collar in this
(p 5 0.005) for distal papillae. Although study as the additional value of a micro-
there were no significant differences in Discussion textured collar is currently unclear
papilla height among the different time The study involved a method for (Cosyn et al. 2007). Besides these geo-
points, a trend towards some recovery immediate replacement of a hopeless metrical implant aspects, osseointegra-
following 3 months of healing was tooth with an implant-supported fixed tion was further optimized as follows:
apparent: at 1 year of follow-up, the prosthesis. For the patient, this appears first, primary implant stability of at least
average papilla loss was 0.41 mm to be an inviting strategy: it is a one- 35 N cm was pursued and considered to
(p 5 0.035) at the mesial aspect of the stage procedure and eliminates the need be a pre-requisite for immediate provi-
restoration, respectively, 0.31 mm for a removable partial denture in the sionalization. This seemed appropriate
(p40.05) at its distal aspect. In Fig. 1e early stages of healing. Thus, the patient because the study of Ottoni et al. (2005)
and f the phenomenon is illustrated. benefits from immediate aesthetics and revealed a correlation between place-
The largest alterations in the midfa- comfort. From a clinical point of view, ment torque and survival of single-tooth
cial level of the peri-implant mucosa the procedure also has its advantages. implants: nine out of 10 failing implants
occurred during the first month of heal- These are mainly related to time gain as were placed with an insertion torque of
ing, pointing to a mean loss of 0.43 mm post-extraction healing and osseointe- only 20 N cm. Appropriate initial inser-
(p 5 0.002). At the 1-year follow-up gration coincide. tion torque was advocated by the
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654 De Rouck et al.

authors to proceed with early loading 1 month of follow-up (3.90 mm) and by the level of the alveolar bone on the
(Ottoni et al. 2005). Second, provisional study termination (3.46 mm). Similar neighbouring tooth (Choquet et al. 2001,
restorations were cleared of all contacts pocket shrinkage was reported by Prous- Kan et al. 2003b). An interesting obser-
to avoid micro-movements, which are saefs et al. (2002) from 3.6 mm at vation in our study is the increase in
sufficient to jeopardize the osseointegra- 3 months to 3.2 mm at 12 months of papilla height between the 3-month
tion process (Brunski 1993, Brunski et follow-up and earlier literature (Apse and the 1-year visit. Although this
al. 2000). Interestingly, the need for et al. 1991). was not statistically consolidated by
these precautions has been questioned Even though ample reports have been our data, the fact that distal papilla
recently by Lindeboom et al. (2006) as published on immediate implant inser- levels were not significantly different
they found no significant differences in tion and provisionalization for replacing from pre-operative levels at the 1-year
any parameter between immediately maxillary anterior teeth, few have docu- re-assessment is indicative of the phe-
loaded and immediately non-loaded pro- mented the aesthetic treatment outcome nomenon. This observation appears to
visionalized implants. (De Rouck et al. 2007). Hence, one of be in line with earlier reports demon-
Radiographic examination 1 year the objectives of this prospective study strating an increase in papillary soft
after implant placement revealed a was to monitor changes in soft tissue tissue volume during the first year of
mean bone loss of 0.98 mm mesially dimensions. Usually, a reference line function of single-tooth implant restora-
and 0.78 mm distally, which is in agree- connecting the midfacial gingival level tions (Chang et al. 1999, Grunder 2000,
ment with other studies on the current of the two teeth adjacent to the implant Cardaropoli et al. 2006).
concept (Lorenzoni et al. 2003, Tsirlis restoration is used for this purpose In this study, significant midfacial
2005). These data are slightly different (Chang et al. 1999, Kan et al. 2003a, soft tissue recession of 0.53 mm in the
from the peri-implant bone changes Cornelini et al. 2005). As midfacial first year of function was found, which
following the conventional two-stage gingival levels may be liable to varia- is in agreement with a report by Kan
procedure in healed sites (Adell et al. tion, especially when mucoperiosteal et al. (2003a) indicating 0.55 mm fol-
1986, Naert et al. 2002). These findings flaps are reflected, an acrylic stent lowing a similar strategy. Cornelini
contribute to the current theory that with fixed reference points was used in et al. (2005) described 0.75 mm midfa-
crestal bone changes are dependent on this study. This method proved highly cial soft tissue loss within the same time
the location of the micro-gap irrespec- reproducible. frame. Other studies have been pub-
tive of submerged or non-submerged In the present investigation, signifi- lished on soft tissue topography follow-
implant placement (Hermann et al. cant reductions in papilla height were ing single-tooth implant placement in
2000, Cosyn et al. 2007). In contrast, found, reaching a maximum of 0.64 mm healed sites demonstrating comparable
three studies on immediate implantation (po0.001) on average for mesial papil- levels of midfacial recession in the first
and provisionalization presented limited lae, respectively, 0.50 mm (p 5 0.005) year of function, yielding to 0.6 mm
bone loss, yielding o0.50 mm after for distal papillae at 3 months of fol- (Grunder 2000, Cardaropoli et al.
1 year of function (Kan et al. 2003a, low-up. Soft tissue swelling may have 2006). By on average 3 years of fol-
Norton 2004, Cornelini et al. 2005). Kan limited papilla loss in the early stages of low-up, midfacial soft tissue loss of
et al. (2003a) even observed several healing explaining less discrepancy in about 1 mm has been described for con-
implants with bone gain, a phenomenon relation to the pre-operative status at ventional single-tooth implant restora-
that was not observed in the present 1 month of follow-up. Interestingly, tions (Chang et al. 1999). These data
study. This could be explained by a our 3-month data on papilla loss seem appear to be slightly different for
difference in the surgical technique. considerably higher in comparison with multiple-unit implant reconstructions
In spite of the fact that plaque levels what has been described earlier by Kan (Bengazi et al. 1996, Small & Tarnow
remained low throughout the study and co-workers (2003a). They reported 2000). In addition, long-term studies
(o20%), nearly half of the sites bled only 0.33 mm mean loss for mesial have demonstrated ongoing soft tissue
upon probing. This is, however, not an papillae, respectively, 0.25 mm for shrinkage up to 1.7 mm, at least in fully
uncommon feature around implants distal papillae at 3 months following edentulous patients (Adell et al. 1986,
(Chang et al. 1999, Lorenzoni et al. single-tooth replacement in the inci- Apse et al. 1991). These findings indi-
1999, Roos-Jansaker et al. 2006, Ozkan sor–cuspid maxillary region by means cate that remodelling is an inevitable
et al. 2007) as a result of an ‘‘inflam- of immediate implant insertion and pro- and continuous event, making long-term
matory cell infiltrate’’ possibly induced visionalization. This disparity can be soft tissue monitoring a necessity. At
by micro-leakage at the implant– explained by the flapless surgical least in the first year of function, our
abutment interface (Broggini et al. approach in their study, resulting in data demonstrate limited loss at the mid-
2003, Piattelli et al. 2003) and the sub- less tissue trauma. However, as the facial aspect, which may be explained as
gingival position of a restoration border present study and the report by Kan et follows: first, patients with a thin-scal-
(Jemt & Pettersson 1993). A relatively al. (2003a) indicate comparable levels loped biotype were excluded in this
high mean probing depth of about of papilla loss after 1 year of function, study. As the risk for aesthetic compli-
3.5 mm after 1 year of function was yielding approximately 0.5 mm for cations is considerably high in these
found in this study, which can be con- mesial papillae and 0.3 mm for distal subjects, hard tissue conditioning and/
sidered to be a normal phenomenon papillae, a possible impact of the surgi- or periodontal plastic surgery are often
around two-piece implants as described cal technique seems negligible in the necessary. These procedures are delicate
by others (Lekholm et al. 1986, Apse et longer run. In this regard, it has been and require a staged approach. Second,
al. 1991, Proussaefs et al. 2002). An well documented that the presence of a Bio-Osss particles were systematically
interesting observation was the decreas- papilla adjacent to a single-tooth enclosed between the implant and the
ing trend in probing depth between implant restoration is principally driven socket wall. Even though resorption of
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Immediate single-tooth implants 655

the alveolar ridge inevitably occurs fol- dehiscencies. Third, flapless surgery Journal of Clinical Periodontology 32,
lowing tooth extraction (Schropp et al. increases the risk of perforation, making 645–652.
2003, Araujo & Lindhe 2005), it has it a risky procedure when implant place- Barone, A., Rispoli, L., Vozza, I., Quaranta, A.
been shown that significantly more buc- ment is not computer navigated. Other & Covani, U. (2006) Immediate restoration
of single implants placed immediately after
cal bone can be preserved when the precautions for flapless implant surgery
tooth extraction. Journal of Periodontology
extraction socket is filled with a grafting in the aesthetic region have been 77, 1914–1920.
material exhibiting a low substitution described recently (Oh et al. 2007). Becker, W., Becker, B. E., Israelson, H., Luc-
rate such as Bio-Osss (Nevins et al. On the basis of the preliminary results chini, J. P., Handelsman, M., Ammons, W.,
2006). As the immediate insertion of an of this study, single-tooth replacement Rosenberg, E., Rose, L., Tucker, L. M. &
implant has no impact whatsoever on by means of mucoperiosteal flap eleva- Lekholm, U. (1997) One-step surgical place-
the dimensional changes of the extrac- tion, immediate implant placement, ment of Branemark implants: a prospective
tion socket (Botticelli et al. 2004, Arau- insertion of a grafting material and the multicenter clinical study. The International
jo et al. 2005), it is conceivable that this connection of a screw-retained provi- Journal of Oral and Maxillofacial Implants
12, 454–462.
bone substitute induces an analogue sional restoration can be considered to
Bengazi, F., Wennstrom, J. L. & Lekholm, U.
effect if incorporated between an be a valuable treatment option. The (1996) Recession of the soft tissue margin at
implant and the socket wall. Evidently, presented protocol also offers many oral implants. A 2-year longitudinal prospec-
this issue should be investigated in con- advantages for the patient as for the tive study. Clinical Oral Implants Research
trolled clinical studies. Because of the clinician. However, careful patient 7, 303–310.
promising properties of Bio-Osss in selection and treatment planning appear Botticelli, D., Berglundh, T. & Lindhe, J. (2004)
this field and because this grafting mate- to be of critical importance in achieving Hard-tissue alterations following immediate
rial does not seem to interfere with a predictable treatment outcome. Evi- implant placement in extraction sites. Journal
osseointegration (Polyzois et al. 2007), dently, further research is needed to of Clinical Periodontology 31, 820–828.
Branemark, P. I. (1983) Osseointegration and its
we choose to apply it at all times in this monitor hard and soft tissue changes
experimental background. The Journal of
study even though the necessity of this on a long-term basis. Prosthetic Dentistry 50, 399–410.
procedure in small bone gaps can be Broggini, N., McManus, L. M., Hermann, J. S.,
considered to be a matter of debate. Medina, R. U., Oates, T. W., Schenk, R. K.,
Finally, screw-retained instead of Acknowledgements Buser, D., Mellonig, J. T. & Cochran, D. L.
cemented provisional restorations were (2003) Persistent acute inflammation at the
used in this study. This may be the The authors wish to thank Prof. Dr. implant–abutment interface. Journal of Den-
reason why no complications were P. Bottenberg for his assistance in digi- tal Research 82, 232–237.
reported during the provisional stage. tizing radiographs and analysing mar- Brunski, J. B. (1993) Avoid pitfalls of over-
In contrast, fistulae have been described ginal bone-level changes and Prof. Dr. loading and micromotion of intraosseous
G. Wackens for his contribution in implants. Dental Implantology Update 4,
when using cemented provisional 77–81.
restorations (Kan et al. 2003a). recruiting and referring patients.
Brunski, J. B., Puleo, D. A. & Nanci, A. (2000)
A flapless surgical technique for ante- Biomaterials and biomechanics of oral and
rior implant placement has been earlier maxillofacial implants: current status and
advocated for optimal aesthetic results future developments. The International Jour-
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tistry 23, 313–323. Vandamme, K., Naert, I., Geris, L., Vander, S. Department of Restorative Dentistry
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Journal of Oral and Maxillofacial Implants Journal of Clinical Periodontology 34, Belgium
15, 527–532. 172–181. E-mail: tim.de.rouck@vub.ac.be

Clinical Relevance vation, immediate implant place- recession was limited to o0.5 mm
Scientific rationale for the study: ment, insertion of a grafting after 1 year of follow-up.
Ample studies have been published material and immediate connection Practical implications: For well-
on immediate placement and provi- of a screw-retained restoration. selected cases, this strategy appears
sionalization of single-tooth implants Principal findings: The cumulative to be a valuable option. The main
in the pre-maxilla. However, no data implant survival rate was 97% in a advantages include time gain and
have been reported on this concept group of 30 patients. Soft tissue immediate aesthetics and comfort.
combining mucoperiosteal flap ele-

r 2008 The Authors

Journal compilation r 2008 Blackwell Munksgaard