In esthetic implant therapy, the patient’sobjective is to obtain an imperceptible,natural-looking prosthetic restoration. For

the clinician, however, the challenge is to findand preserve—or to regenerate—hard andsoft tissues that will allow for a thick, stableperi-implant environment. In the anterior zone,the loss of a tooth or teeth is often due totrauma, infection, or poor treatment. Suchtooth loss may affect the bone and/or thegingival architecture, making immediateimplantation after extraction impossible ormore difficult to achieve.

Moreover, there are several specificanatomical features of anterior sockets that make thistreatment more challenging. How the latter should bemanaged, and how and when the implant should beinstalled are among the many parameters that make implantsurgical and prosthetic treatments successful and their bio-esthetic integration harmonious and stable.

Socket Management

In the 90s, the hypothesis was that implant placement intoan extraction socket may counteract hard tissue resorption(Denissen et al 1993 IJOMI, Watzek et al 1995 IJOMI). In2004, Botticelli determined that while newly formed hardtissue had filled the marginal gaps surrounding implants inextractions sites, the buccolingual dimensions of the ridgewere considerably altered. On 18 patients with 21 implants,he observed after four months a buccal loss greater than50% and a lingual loss of approximately 30%.

Recently, several investigators have confirmed theoccurrence of this tissue alteration, despite the presence ofan immediately placed implant (Covani et al 2004, Ferrus etal 2009, Sanz et al 2009, Araujo et al 2005, Cardarpoli et al

Immediate Implant Placement:

Parameters Influencing Tissue Remodeling

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2005, Fickl et al 2008, Fugazzoto 2005, Chen et al 2005,Huynh-Ba et al 2010). Therefore, a bone substitute needs tobe grafted in the alveolus around the implant in order forthese large gaps to be completely resolved and resorptionto be prevented (Ferrus et al).

It must be noted that not all sockets show the samemagnitude and speed of remodeling. Patients classified ashaving a thin tissue biotype show greater recession,vertically and horizontally, than do those with thick

biotypes. Evans et al found 1 mm recession (±0.9 mm) inpatients with a thin biotype versus 0.7 mm (±0.57 mm) inthick biotypes (Evans et al 2008). While tissue thicknessplays a crucial role in this alteration process, it has to beconsidered that most buccal bone plates are thin or verythin in the anterior zone. According to Huynh-Ba et al(2010), only 2.6% of maxillary incisors and canines havetheir bone plate widths greater than or equal to 2 mmwhich, according to Spray et al (2004), would be thecritical thickness of the facial bone plate in extraction sitesto reduce the remodeling; this dimension has beenconfirmed by Belser et al (2007) for healed sites.

In computed tomography images, it is common toobserve very thin buccal plates (sometimes nearlyundetectable) around teeth or with large dehiscences—even while the gingival architecture remains stable formany years with small, if any, soft tissue recession aroundthese teeth. In the case of extraction or immediate

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implantation, however, and even with bone substitute inthe gap (i.e., socket preservation), thin bone plates tend toslowly disappear. Consequently, some clinicians routinelygraft connective tissue in this situation to counteract thepossible perforation or dehiscence of the soft tissue.

This ongoing alteration of the socket wall is very likelydue to the quality of this bone, predominantly composedof bundle bone, and underlines the importance of tissuebiotype. The lack of stimulation and function caused bythe absence of Sharpey’s fibers and the periodontalligament may explain this remodeling, yet it is lesspronounced in lingual walls that have more lamellar bone.

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After a simple extraction, a tight blood clot containinggrowth factors is formed. The socket heals in approximately 8weeks, with internal bone regeneration as well as resorption ofthe buccal and lingual walls (Rompen 2010). As possible,socket management performed at the time of implantinsertion aims at preventing this resorption rather than aidingin regeneration, for which the blood clot is sufficient.

About the Gap

When an implant is inserted in a socket, a horizontal gapexists between the implant body and neck and the bonywalls. Since buccal gaps will not predictably and completelyresolve alone, grafting materials have become increasinglypopular among clinicians (Ferrus et al), and their role is toreduce the bone alteration, especially horizontally, aroundthe implant. The latter and its cervical diameter mayinfluence the amount of bone loss. Sanz et al (2010) havestudied this impact and concluded that alterations in thebuccal ridge, as well as the horizontal and vertical gapsbetween implants and bone walls, were greater in casesinvolving a smaller implant neck design. A small gap is notthe solution (Araujo et al 2005), and the widest implantshould not be selected, particularly with modern implantdesigns that offer high initial stability. A wide gap is notdesirable either (Ferrus et al 2010) and will not be completelyfilled with bone if one relies only on the blood clot.

Ideally, implants should be installed into extractionsockets in a lingual position, often partially at the expense ofthe lingual bone plate, and approximately 1 mm deeper thanthe level of the buccal alveolar crest (Caneva et al 2010,Becker et al 2008, Buser et al 2008). Therefore, a horizontalbuccal gap of 1 mm to 2 mm seems clinically acceptableand should be filled with a bone substitute.

In the anterior zone prior to any extraction and/orplanning of immediate implant placement, a pretreatmentrisk assessment and full understanding of the patient'sesthetic expectations should be conducted. The quantityand quality of hard and soft tissues must be carefullyevaluated to validate this treatment option.

Some deficiencies require delayed implant placementafter socket management and tissue healing have occurred.Immediate implant placement and temporization is a valid,evidence-based procedure but technique sensitive andinfluenced by multiple parameters (anatomical, surgical,prosthetic, infection, implant and abutmentdesign/surface/material, etc.). As this technique does notprevent some type of remodeling of hard and soft tissues,especially for thin and moderate biotypes, soft tissuegrafting may also be considered at the time of surgery orlater, with connective tissue or recent collagen substitutes.Clinically, in patients with a thin biotype, theextraction/implantation procedure is now a more invasivetreatment if the practitioner’s underlying objective is to avoidesthetic complications.

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In immediate temporization,a definitive abutment ispreferred to a temporaryabutment (particularly if it is anon-biocompatible materialsuch as a polymer), which isusually connected anddisconnected several times.Its transmucosal aspect mustbe undercontoured andinwardly oriented (i.e.,Curvy® Nobel Biocare) ordisplay a platform-switchingcontour. Touati et al (2005)and Rompen et al (2003 and2007) have shown that byaugmenting and stabilizingthe soft tissue— through connective tissue thickening andlocking—tissue remodeling is reduced, improving theesthetic outcome and the natural integration of theprosthetic restoration.

Canullo et al (2010) have recently shown in arandomized, controlled study that marginal bone levelswere better maintained in implants restored according to

the platform-switching concept. This creates a similareffect as Curvy® Nobel Biocare abutments and augmentsthe horizontal distance between the implant/abutmentconnection and the inflammatory infiltrate in theconnective tissue. Several other parameters, while beyondthe scope of this article, also impact tissue remodelingand should be always taken into account.

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About the AuthorsBernard Touati, DDS, MS is a visitingprofessor at the Hadassah Faculty of DentalMedicine in Jerusalem. He is past-president ofthe European Academy of Esthetic Dentistryand founder/past-president of the FrenchSociety of Esthetic Dentistry. He is a memberof the American Academy of RestorativeDentistry and the American Academy of

Esthetic Dentistry. He is Editor-in-chief of “Practical Proceduresand Aesthetic Dentistry”, an international lecturer and author ofnumerous publications. Bernard is co-academic director of theGlobal Institute for Dental Education.

Mario Groisman, DDS, MSc is a professor of thepost-graduate course in oral implantology at SãoLeopoldo Mandic University and has a privatepractice in Rio de Janeiro, Brazil. He is a specialistin Periodontology at the University of State of Riode Janeiro, as well as a specialist in oralimplantology, CFO.

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