Immediate implants

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IMMEDIATE IMPLANTS

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CONTENTSIntroductionAims of therapyDiagnosis and treatment planningCriteria for case selectionThe rule of 5 triangles to decision-making processAdvantagesDisadvantages IndicationsContraindications Classifications of immediate implant placement (IIP)Tooth extraction and implant placement proceduresThe bony gapFactors influencing the outcome of IIP Soft tissue management of immediate implants

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CONTENTSIIP in infected socketsIIP in periapical infectionsHistological outcomesChanges inside the alveolar socketDimensional alterations of the alveolar bone crestInfluence of implant Influence of socket anatomyInfluence of surgical protocolMorphogenesis of peri-implant mucosaImmediate implant placement (IIP) vs. spontaneous healing of the socket

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Clinical outcomesSurvival ratesHard-tissue changesInterproximal hard-tissue changesSoft tissue healing/esthetic outcomesInterdental papillaeBiological complicationsRecommendations for clinical practiceReferences

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5I. INTRODUCTION

Missing teeth and supporting oral tissues have traditionally been replaced with dentures or bridges permitting restoration of chewing function, speech, and aesthetics.Dental implants offer an alternative. They are inserted into the jawbones to support a dental prosthesis and are retained because of the intimacy of bone growth on to their surface. This direct structural and functional connection between living bone and implant surface, termed Osseointegration, was first described by Brnemark 1977 and has undoubtedly been one of the most significant scientific breakthroughs in dentistry over the past 40 years.6Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate-delayed and delayed implants) (Review). Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Teeth may have been lost through dental disease or trauma or they may be congenitally absent. However in many clinical situations compromised teeth or roots may still be present in the patients mouth. Traditionally, before placing dental implants, compromised teeth were removed and the extraction sockets were left to heal between several months and 1 year.Original protocols required the placement of implants into healed edentulous ridges. Branemark 1977; Adell 1981.

7Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate-delayed and delayed implants) (Review). Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

8BRANEMARKS ORIGINAL PROTOCOL

The Negatives Of Delayed Implant PlacementVolume loss of alveolar bone Increased time of edentulism Longer treatment time Additional surgical procedure Psychological impact on the patient

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Immediate implant placement after tooth extraction has become a common surgical protocol in clinical practice. This therapeutic concept was introduced in Scheult & Heimke 1976 as an alternative protocol to the classical delayed implant surgical protocol proposed by Branemark.In 1989, Lazzara placed implants at the time of tooth extraction.10Vignoletti and Sanz. Immediate implants at fresh extraction sockets: from myth to reality. Periodontol 2000 2014;66:133-52.Branemark PI. Osseointegration and its experimental background. J Prosthet Dent 1983:50:399410.Schulte W, Heimke G. The Tubinger immediate implant. Quintessenz 1976: 27: 1723.

In the 1990s, these protocols were modified to include implant placement in fresh extraction sockets [Schwartz-Arad and Chaushu 1997; Mayfield 1999] or in partially healed alveolar ridges [Nir-Hadar et al 1998] predominantly for implants in the esthetic zone.However, the great majority of patients are interested in shortening the treatment time between tooth extraction and implant placement, or even better in having the implants inserted during the same session as the teeth are extracted.11Chen et al. Esthetic Outcomes Following Immediate and Early Implant Placement in the Anterior MaxillaA Systematic Review Int J Oral Maxillofac Implants 2014;29(Suppl):186215.Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

Currently, implants are also being placed in fresh extraction sockets, Infected sockets,periapical infected sites,the area of the maxillary sinus, etc.

12Hammerle et al. Timing of implant placement. Lindhe J. 5th ed

Hammerle et al. Timing of implant placement. Lindhe J. 5th ed.12

II. AIMS OF THERAPY13

During the surgical phase of therapy, ideal conditions must be established for successful bone and soft tissue integration to the implant. In a growing number of cases, however, treatment must also satisfy demands regarding the esthetic outcome. In such cases, the overall surgical and prosthetic treatment protocol may become more demanding, since factors other than osseointegration and soft tissue integration may play an important role.14Hammerle et al. Timing of implant placement. Lindhe J. 5th ed

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15Hammerle et al. Timing of implant placement. Lindhe J. 5th ed

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In cases where the restoration of health and function constitutes the primary goal of the treatment, the location and volume of available hard and soft tissues are the important factors to consider. The replacement of a single-rooted tooth with an implant in a fully healed ridge will, in most cases, ensure proper primary stability with the implant in a correct position.16Restoration of health and function

Also, the soft tissues are sufficient in volume and area. The mucosal flap can be adapted to the neck (or the healing cap) of the implant (one-stage protocol).When primary wound closure is intended (two-stage protocol), mobilization of the soft tissue will allow tension-free adaptation and connection of the flap margins.

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When an implant is placed in the fully healed site of a multi-rooted tooth, the surgical procedure becomes more demanding.Often the ideal position for the implant is in the area of the inter-radicular septum.If the septa are delicate, anchorage for primary implant stability may become difficult to achieve.In molar sites, there is often only a small amount of soft tissue present. This may create a problem with respect to wound closure with a mobilized, tension-free flap. In some molar sites, primary wound closure may not be possible at times following implant installation.18

The presence of marginal defects (gaps) between the implant and the fully healed ridge following type 4 placement significant problem that could compromise osseointegration.In such a horizontal marginal defect (gap) of 2 mm, new bone formation as well as defect resolution and osseointegration of the implant (with a rough titanium surface) will occur.[Wilson et al. 1998; Botticelli et al. 2004; Cornelini et al. 2005].19

The replacement of missing teeth with implants in the esthetic zone is a demanding procedure. Deficiencies in the bone architecture and in the soft tissue volume and architecture may compromise the esthetic outcome of treatment (Grunder 2000).Botticelli et al. 2004 Placed implants in fresh extraction sockets. During healing, the implants became clinically osseointegrated within the borders of the previous extraction socket. However, significant loss of buccal bone height (contour) also occurred. In esthetically critical situations, this loss of contour may lead to a compromised outcome. Hence not infrequently, tissue augmentation procedures must be performed in the esthetic zone.

20Esthetic importance and tissue biotype

Also, when a two-stage implant placement protocol is used, the labial mucosa will recede following abutment connection surgery (Mean values - 0.5 - 1.5 mm). These findings additionally stress the necessity for a careful treatment approach when implants are placed in the esthetic zone.The biotype of the soft and hard tissue tissues may play a role regarding the esthetic outcome of implant therapy. The scalloped thin biotype is associated with a delicate bone housing.Evans and Chen 2007 Buccal tissue recession at single-tooth implants was more pronounced in patients exhibiting a thin biotype compared to patients with a thick biotype.21

III. DIAGNOSIS AND TREATMENT PLANNING22

In general, immediate dental implant selection criteria are contextually dependent on the unique circumstances that pertain to each individual patient and should reflect the following factors:Thorough medical and dental histories,Clinical photographs, Study casts, Periapical and panoramic radiographs,Linear tomography/computerized tomography/CBCT of the proposed implant sites.23Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

Determining the overall vs. individual prognosis.Reasons for tooth extraction [Becker et al 2000]Insufficient crown to root ratio, Remaining root length, Periodontal attachment level, Furcation involvement, Periodontal health status of teeth adjacent to the proposed implant site, Non-restorable caries lesions, Root fractures with large endodontic posts, Root resorption,24Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

Root perforation,Periapical pathology,Questionable teeth in need of endodontic retreatment.Implants to replace teeth with nonvital pulp, fractured at the gingival margin with roots shorter than 13 mm, is often considered the treatment of choice [Lovdahl 1992].

25Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

In esthetic zone The scalloping of the periodontium,Level of crestal and interproximal bone, Smile line, and Morphology of the gingival tissues.[Ochsenbein 1969; Becker et al 1997;Kan et al 2003; Kois 2004]Proposed inter-implant distance,Existing contact relationships and interproximal bone. [Tarnow et al 1992, 2003]26Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

Radiographic examination Available boneBone shape, Bone quality, Bone quantity, Bone width, Bone height.A minimum of 45 mm of bone width at the alveolar crest, and at least 10 mm bone length from the alveolar crest to a safe distance above the closest anatomical structure are recommended [Worthington 2004].27Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

Philip Worthington. Injury to the inferior alveolar nerve during implant placement: A formula for protection of the patient and the clinician. Int J Oral Maxillofac Implants 2004;19:731-34.In some patients, there may be a thin ridge of bone at the crest that will project onto the panoramic film but which in practice may be useless for implant accommodation unless a bone augmentation procedure is used. This crestal ridge of relatively useless bone must be taken into account. The magnification factor of an individual panoramic machine must be known and factored into the calculation of the permissible implant length.28

Safety zone A small space between the tip of the implant (or the preceding drill) and the anatomical landmark.If H is the height of bone apparently available above the anatomical landmark on the panoramic film, c is the height of useless bone at the crest, s is the safety zone (for this example, a safety zone of 2 mm will be used), m is the magnification factor (eg, if there is 25% magnification, m would be 54), and L is the permissible implant length,29

Philip Worthington. Injury to the inferior alveolar nerve during implant placement: A formula for protection of the patient and the clinician. Int J Oral Maxillofac Implants 2004;19:731-34.

L = (H/M) c s .For example, if H = 15 mm measured on a panoramic radiograph, c = 2 mm, s = 2 mm, and m = 5/4, then L = 8 mm (Implant length).if c = 0, then L = 10 mm.

30Philip Worthington. Injury to the inferior alveolar nerve during implant placement: A formula for protection of the patient and the clinician. Int J Oral Maxillofac Implants 2004;19:731-34.

31Philip Worthington. Injury to the inferior alveolar nerve during implant placement: A formula for protection of the patient and the clinician. Int J Oral Maxillofac Implants 2004;19:731-34.

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A satisfactory esthetic result in the esthetic zone requires the interproximal bone height to be 5 mm or less, when measured from the contact point of the adjacent tooth. As the distance from the contact point to the interproximal bone increases, the likelihood of retention of the interproximal papillae after implant placement diminishes. Patients must be made aware of potential esthetic shortcomings if implants are placed in compromised esthetic zones.32Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

Once a patient is considered a candidate for immediate implant, a surgical guide may be used to assure proper implant placement. A provisional appliance with an ovate pontic for insertion after implant placement [Johnson and Leary 1992; Dylina 1999; Zitzmann et al 2002]. 33Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

IV. CRITERIAS FOR CASE SELECTION34

35McNutt MD, Chou CH. Current Trends in Immediate Osseous Dental Implant Case Selection Criteria. Journal of Dental Education 2003;67[8]:850-9.

McNutt MD, Chou CH. Current Trends in Immediate Osseous DentalImplant Case Selection Criteria. Journal of Dental Education 2003;67[8]:850-9.35

36Ajay Kumar. Criteria for immediate placement of oral implants a mini review . Biology and Medicine 2012;4(4): 188192

Ajay Kumar. Criteria for immediate placement of oral implants a mini review . Biology and Medicine 2012;4(4): 18819236

V. THE RULE OF 5 TRIANGLES TO DECISION-MAKING PROCESS37http://www.eao.org/new-protocol-immediate-implants-rule-5-triangles-case-report-pages-4-5-0#sthash.MVa02QQH Gracia et al 2014.

There are 5 key aspects to follow in placing an immediate implant in order to reach favorable outcomes, these are the 5 triangles 38

Placing an immediate implant requires sufficient bone apical to the extracted socket.An approximate 2-4 mm of bone apical to the alveolus is necessary in order to have a greater possibility of obtaining a stable anchor, and thus obtain stability. This can be enhanced by the type of implant used, which is of a tapered design. 391. Primary stability where there is existing apical bone

In a multi-center study of 2667 implants, minimal bone loss was shown in sites with more than 1.8-2.0 mm of facial bone [Spray et al 2000]. This implied that buccal bone thickness is important in predicting the resorption of the buccal plate.

The buccal bone is a critical aspect, and the first triangle, in order to prevent esthetic complications [Park 2010].402. The presence of buccal plate

Presence of a 2 mm buccal plate is crucial to avoid soft tissue recession. [Grunder et al 2005; Juodzbalys et al 2008].A horizontal buccal bone width of at least 2 mm should remain at the end of the resorption phase, allowing for the conical peri-implant bone resorption to remain inside the width of the bone wall.[Spray et al 2000;Grunder et al 2005]Sites with IIP were found to have marked apical displacement of the buccal plate with no vertical bone loss in the lingual aspect [Vignoletti et al 2009]. The mean vertical differences between buccal and lingual alveolar crest was approx. 1 mm [Vignoletti et al 2012].

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Close adaptation of the implant to the socket wall promotes greater osseointegration.

3. Jumping distance (Filling of the gap between buccal plate and implant)/Horizontal Defect Dimension

Bone healing in an implant osteotomy proceeds apical to coronal, much like that of an extraction socket; therefore, the coronal aspect becomes the most critical in the healing. Current research favors the use of an occlusive barrier membrane to protect the healing socket area.42

When immediate implants are placed, peri-implant voids are frequently present due to a gap between the alveolar socket and the implant.Resorption prevails during healing when the gap is large and the biotype is thin.[Araujo et al 2006; Tomasi et al 2010].43Capelli et al. Implant-Buccal plate distance as a diagnostic parameter: A prospective Cohort Study on implant placement in fresh extraction sockets. J Periodontol 2013;84[12]:1768-74.

Capelli et al. Implant-Buccal plate distance as a diagnostic parameter: A prospective Cohort Study on implant placement in fresh extraction sockets. J Periodontol 2013;84[12]:1768-74.43

In order to compensate for the expected horizontal bone resorption of the buccal plate, the use of bone substitutes, with a low resorption rate, to fill the gap has been shown to reduce this resorption significantly and therefore their use should be advocated when the esthetic demands are high.44

Vignoletti and Sanz. Immediate implants at fresh extraction sockets: from myth to reality. Periodontol 2000 2014;66:133-52.

Arajo et al 2011 Filling the gap with deproteinized bone mineral has beneficial outcomes: Hard tissue healing process is modified,Additional hard tissue is present at the re entrance of the socket after a period of bone healing, Soft tissue recession is prevented, and There is an improvement of the marginal bone-to-implant contact.45Arajo MG, Linder E, Lindhe J. Bio-Oss collagen in the buccal gap at immediate implants: a 6-month study in the dog. Clin Oral Implants Res 2011;22(1):1-8.

In the intact socket , a critical component of the peri implant defect is the size of the horizontal defect (HD) .

Implants with a HD of 2 mm to achieve bone healing, bone fill, likely by using collagen barrier membrane & implants with a sand blasted & acid etched surface.46

WHEN TO CONSIDER GRAFTING PROCEDURES?If any osseous defect exists circumferentially.If there is translucence of implant on labial /buccal bone.If there is residual exposure of implant body.If dehiscence or fenestration exists.If there is primary closure of soft tissue flaps.If vertical releasing incision is necessary.

The patients biotype, is also of crucial importance, being more favorable, if its thick rather than thin [Park 2010].

Thin and thick tissue biotypeswere previously defined as < 1.5 mm and > 2 mm tissue thickness [Claffey and Shanley, 1986].

A thin tissue biotype increased the risk of mucosal recession around dental implants [Chen and Buser 2009; Chen et al 2009; Evans and Chen 2008; Kan et al 2011].

484. Tissue biotypeWang et al. using soft tissue graft to prevent mid-facial mucosal recession following immediate implant placement. J Int Acad Periodontol 2012;14[3]:76-82

Wang et al. using soft tissue graft to prevent mid-facial mucosal recession following immediate implant placement.JIAP 2012;14[3]:76-82 48

Thin Biotype

Thin scalloped biotype (15% prevalent)Distinct disparity between location of gingival margin facially and interproximally.Delicate and friable soft tissue.Small amount of attached gingiva.

Thick flat biotype--more prevalent (85%).Adequate amount of attached gingiva.Dense fibrotic soft tissue.Ideal for placing implants.

Thick Biotype

Different implant designs influence the biomechanics of the environment where an immediate implant is placed. To enhance primary stability, self-tapping implants were developed, which compress the alveolar bone as the implant is inserted.

515. Implant design.

VI. ADVANTAGES52Ataullah et al. Implant placement in extraction sockets: a short review of the literature and presentation of a series of three cases. J Implantol 2008;34[2]:97-106

53Patient acceptability.Reduces the treatment time & interval during the transitional period.Socket as a guide for determination of parallelism & alignment to the opposing & adjacent teeth. Surgeon can position the implant more favorably than the original position. Facilitates final restoration & minimizes need for severely angled abutments /fabrication of telescopic copings. Implants in extraction sites can be placed in the same position as the extracted teeth.Maintenance of soft tissue profile.Prevention of bone loss in both vertical and horizontal directions.53Ataullah et al. Implant placement in extraction sockets: a short review of the literature and presentation of a series of three cases. J Implantol 2008;34[2]:97-106

VII. DISADVANTAGES54Ataullah et al. Implant placement in extraction sockets: a short review of the literature and presentation of a series of three cases. J Implantol 2008;34[2]:97-106Bhola et al. Immediate Implant Placement: Clinical Decisions, Advantages, and Disadvantages. Journal of Prosthodontics 2008;17:576581

Bhola et al. Immediate Implant Placement: Clinical Decisions,Advantages, and Disadvantages. Journal of Prosthodontics 2008;17:57658154

Technically more demanding procedure.Lack of control on final implant position.Difficulty in obtaining primary stability.More extensive soft tissue manipulation.Site morphology may complicate optimal implant placement and anchorage.Thin tissue biotype may compromise optimal outcome.Potential lack of keratinized mucosa for flap adaptation.Added cost of bone grafting.55

VIII. INDICATIONS56

Non-restorable deep carious lesions,An endodontically infected tooth, Root fracture (vertical/horizontal), Root resorption,Periodontal infection, Periapical pathology, Root perforation, and Unfavorable crown to root-ratio (not due to periodontal loss). 57

IX. CONTRAINDICATIONS58

Inadequate height or width of bone,Lack of soft tissue,Adverse location of anatomical structures, Proximity of adjacent teeth, Failure to achieve primary stability,Inability to attain a restoratively driven position, Angulation or depth of the implant.Unfavorable extraction site morphology.59

X. CLASSIFICATIONS OF IMMEDIATE IMPLANT PLACEMENT 60

SCHOOL OF THOUGHTS:-WILSON AND WEBER 1993.[Classification of and therapy for areas of deficient bony housing prior to dental implant placement. Int J Periodont Rest Dent 1993;13:451-9]IMPLANT PLACEMENTADVANTAGESDISADVANTAGESIMMEDIATESame appointment as extraction.- No additional pre-implant surgery. No waiting for socket healing.- Membrane exposure. Comparatively, increased possibility of infection.RECENT 30-60 days (4-8 weeks)after extraction.- Less possibility of membrane exposure. Minimal waiting for socket healing.An additional pre-implant surgery.Possibility of infection around membrane.DELAYEDFollowing hard tissue maturation - Allows healing to occur. Produces dense bone when bone graft is used.An additional pre-implant surgery.Possibility of infection around membrane.MATUREMonths to years after extraction- Allows implant placement when previously not possible. Can be used to enhance bony ridges.An additional pre-implant surgery.Technically difficult.Possibility of infection around membrane.

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632. MAYFIELD 1999. [Proceedings of 3rd European World Workshop in Periodontics]IMPLANT PLACEMENTIMMEDIATESame appointment as extraction (0 weeks).DELAYED6 - 10 weeks after extraction.LATE 6 months after extraction.

Chen et al. Immediate or Early Placement of Implants Following Tooth Extraction: Review of Biologic Basis, Clinical Procedures, and Outcomes. INT J ORAL MAXILLOFAC IMPLANTS 2004;19:1225

Most of the studies reviewed described IIP as part of the same surgical procedure and immediately following tooth extraction, EXCEPT 64AUTHORSIMMEDIATE IMPLANT PLACEMENTGOMEZ-ROMAN et al 1997Defined it as occurring between 0 7 days following tooth extraction.SCHROPP et al 2003Defined as Implants placed between 3 15 days (mean 10 days) following tooth extraction.



65AUTHORSEARLY IMPLANT PLACEMENTHAMMERLE et al 2004; SANZ et al 2011.This intervention was defined at a consensus workshop as Implant placed following tooth extraction when the complete soft tissue healing of the socket (typically 4 8 weeks after extraction) has occurred.



The majority of studies that described delayed implant placement used a delay period of 4 - 8 weeks following extraction, EXCEPT

66Chen et al. Immediate or Early Placement of Implants Following Tooth Extraction: Review of Biologic Basis, Clinical Procedures, and Outcomes. INT J ORAL MAXILLOFAC IMPLANTS 2004;19:1225AUTHORSDELAYED IMPLANT PLACEMENTHAMMERLE and LANG 20018 - 14 weeks following tooth extraction.ZITZMANN et al 1996, 1997Between 6 weeks and 6 months following tooth extraction.GOMEZ-ROMAN et al 19971 week and 9 months following tooth extraction.

A.1. BASED ON THE TIMING OF PLACEMENT OF IMPLANTS IN EXTRACTION SOCKET[HAMMERLE et al 2004]67Hammerle et al. Consensus Statements and Recommended Clinical Procedures Regarding the Placement of Implants in Extraction Sockets. Group1 Consensus Statement. Int J Oral Maxillofac Impl 2004;19:26-28.Lindhe 5th and 6th Ed.

68IMPLANT PLACEMENTADVANTAGESDISADVANTAGESType 1 [IMMEDIATE]Same surgical procedure and immediately following extraction.Reduced number of surgical procedures.Reduced treatment time.Optimal availability of existing bone.- Site morphology may complicate the optimal placement and anchorage.Thin tissue biotype may compromise optimal outcome.Potential lack of keratinized mucosa for flap adaptation.Adjunctive surgical procedures may be required.Technique sensitive.

Indicated in Cases where Restoration of health and function with respect to the location and volume of both hard and soft tissues is the primary goal.69

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70IMPLANT PLACEMENTADVANTAGESDISADVANTAGESType 2 [EARLY WITH SOFT TISSUE HEALING]Complete soft tissue coverage of the socket; typically 4-8 weeks.Increased soft tissue area and volume facilitates soft tissue management.Allows resolution of local pathology to be assessed.Site morphology may complicate the optimal placement and anchorage.Increased treatment time.Varying amounts of resorption of the socket walls.Adjunctive surgical procedures may be required.Technique sensitive.

Indicated in Esthetic zone.Compromised buccal plate.Resolution of the pathology.Soft tissue bulk.Pronounced scalloped biotype.

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Type 372IMPLANT PLACEMENTADVANTAGESDISADVANTAGESType 3 [EARLY WITH PARTIAL BONE HEALING]Substantial clinical and/or radiographic bone fill of the socket ; typically 12-16 weeks. Substantial bone fill of the socket.Mature soft tissue facilitates flap management.Increased treatment time.Varying amounts of resorption of the socket walls.Adjunctive surgical procedures may be required.

Indicated in Pronounced scalloped biotype.Placing the implant in a position that facilitates the prosthetic phase of the treatment.

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Type 474IMPLANT PLACEMENTADVANTAGESDISADVANTAGESType 4 [LATE]Healed site; typically >16 weeks. Clinically healed Mature soft tissue facilitates flap management.Increased treatment time.Large variation in available bone volume.Adjunctive surgical procedures may be required.

Indicated in - Completely healed ridge.

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A.1. BASED ON THE TIMING OF PLACEMENT OF IMPLANTS IN EXTRACTION SOCKET[QUIRYNEN et al 2007]76Quirynen et al. How Does the Timing of Implant Placement to Extraction Affect Outcome? INT J ORAL MAXILLOFAC IMPLANTS 2007;22(SUPPL): 203223

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A.2. BASED ON THE TIMING OF PLACEMENT OF IMPLANTS IN EXTRACTION SOCKET[ESPOSITO et al 2010]78

Esposito et al. Timing of implant placement after tooth extraction: immediate, immediate-delayed or delayed implants? A Cochrane systematic review. Eur J Oral Implantol 2010;3(3):18920579IMMEDIATEAny implant placed in a fresh extraction socket just after tooth extraction.IMMEDIATE-DELAYEDAny implant placed in an extraction socket within 8 weeks after tooth extraction.DELAYEDAny implant placed at least 2 months ( 8 weeks) after toothextraction.

B. 1. BASED ON BUCCAL BONE AND SOFT TISSUE PROFILE[FUNATO et al 2007]80Funato el at. Timing, Positioning, and Sequential Staging in Esthetic Implant Therapy: A Four-Dimensional Perspective. Int J Periodontics Restorative Dent 2007;27:313-23

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Class 1 Intact buccal bone with thick biotype. Incisionless implant placement without flap reflection is viable.

Class 2 Intact buccal bone with a thin, more scalloped gingival biotype. Incisionless implant placement is viable, but in combination with a connective tissue graft or a subsequent connective tissue graft (Staged).

Class 3 Deficient buccal bone within the alveolar housing and indicated to have limited and acceptable results with immediate placement with guided bone regeneration plus connective tissue graft.

Depending on the degree of compromise to the buccal plate, the case may alternatively be handled in a staged approach using a socket augmentation procedure and subsequent implant placement.In many cases, particularly with thin biotypes, this method provides a more predictable and safer outcome. 86

Class 4 Deficient buccal bone deviating from alveolar housing and implant placement within the remaining palatal bone results in a significantly off-axis implant position.

If performed immediately, the long axis of the implant inclines toward the buccal and will result in a significant esthetic compromise of the definitive restoration. In these situations, the delayed approach should be used with subsequent 3D bone and soft tissue augmentation of the deficient ridge followed by optimal implant positioning.88

B. 2. BASED ON IMPLANT POSITIONING and THE RESULTING LONG AXIS [FUNATO et al 2007]89Funato el at. Timing, Positioning, and Sequential Staging in Esthetic Implant Therapy: A Four-Dimensional Perspective. Int J Periodontics Restorative Dent 2007;27:313-23

Vertical depth of implant head and direction of long axisThe platform of the implant should be located 2 - 4 mm below the mid-facial aspect of the free gingival margin, with the extended long axis directed slightly lingual to the incisal edge of the definitive restoration.

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When the long axis of the implant is inclined labially and projects beyond the incisal edge of the definitive restoration, the result is that the subgingival contours of the abutment or restoration will tend to deflect the gingival margin apically, resulting in an unharmonious esthetic profile.[Saadoun and Le Gall 2003]91

To correct this problem, the profile extending from the implant head to the free gingival margin requires a straight or negative angulation.Immediate placement generally cannot be performed in the wrong position without esthetic compromise.92

C. CLASSIFICATION OF EXTRACTION SOCKETS BASED UPON SOFT AND HARD TISSUE COMPONENTS[JUODZBALYS et al 2008]93

a. Soft tissue variables1. Contour variationsVertical distance between the socket and adjacent teeths buccal gingival scallop margin.94No gap< 2 mm > 2 mmAdequateCompromisedDeficient

a. Soft tissue variables2. Vertical Soft tissue deficiency Vertical distance between the socket and adjacent teeths buccal mucosa tissues margin.95

No gap1 - 2 mm > 2 mmAdequateCompromisedDeficientCompromised esthetic resultSoft tissue augmentation prior to implant insertion

a. Soft tissue variables3. The keratinized gingival (KG) width on the mid-buccal side of the socket.96

2 mm1 - 2 mm < 1 mmAdequateCompromisedDeficientOptimal for esthetic restoration

The existing KG helps tight tissue adaptation and provides a connective tissue circumferential fiber system that resists mechanical stress. [Sevor 1992].

a. Soft tissue variables4. Gingival tissue Biotype97

2 mm 1 - < 2 mm < 1 mmThickModerateThin

Claffey N, Shanley D. Relationship of gingival thickness and bleeding to loss of probing attachment in shallow sites following nonsurgical periodontal therapy. J Clin Periodontol 1986;13:654-657.

a. Soft tissue variables5. Soft tissue quality98

Pink and firm with normal contourSlightly red, soft and spongy with uneven contourSoft, edematous and boggy or crater-like appearanceAdequateCompromisedDeficient

a. Hard tissue variables1. Height of the alveolar process99

Distance between the tip of the extraction socket labial plate and the nasal sinus floor. 10 mm 8 - < 10 mm 8 mmAdequateCompromisedDeficient

It is the distance between the socket apex and the nasal sinus floor. To achieve implant primary stability, available bone beyond the extraction socket margin should be 4mm (or 3mm in case of compromised bone height) [Nemscovsky 2002; Juodzbalys 2003].100a. Hard tissue variables2. Available bone beyond the apex of extraction socket

101a. Hard tissue variables3. Extraction socket labial plate vertical position

The distance between the tip of the extraction socket labial plate and the CEJ of the adjacent teeth. 3 mm> 3 - < 7 mm 7 mmAdequateCompromisedDeficientGBRIIP contraindicated.

102a. Hard tissue variables4. Extraction socket facial bone thickness

Measured at the 1-, 2-, 3-, 4-, 5- and 6-mm levels with ridge mapping calipers.To maintain the implant soft tissue profile and to ensure implant esthetics, a minimal labial plate width of 1 - 2 mm is needed. [Spray et al 2000; Kazor et al 2004]

Periodontal and traumatic bone lesions often jeopardize the success of immediate implant procedures.[Novaes et al 2003]103a. Hard tissue variables5. Presence of extraction socket bone lesionsa. Hard tissue variables6. Intradental bone peak height

3 - 4 mm 1 - < 3 mm< 1 mmAdequateCompromisedDeficient

104a. Hard tissue variables7. Mesio-Distal (M-D) distance between adjacent teeth

7 mm 5 - < 7 mmIdealCompromised

A minimum of 1.25 - 1.5 mm of clearance is needed between the implant fixture and adjacent teeth for proper osseointegration and safety.

105a. Hard tissue variables8. Palatal angulation< 55 - 30AdequateCompromised

106Treatment Recommendation Based on the Proposed ClassificationType I (Adequate)IIPType II (Compromised)Immediate or Delayed with simultaneous soft or hard tissue augmentationType III (Deficient)Soft and hard tissue augmentation or orthodontic treatment followed by Staged implantation.

107XI. TOOTH EXTRACTION AND IMPLANT PLACEMENT PROCEDURESLazzara. Immediate implant placement into extraction sites: Surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9[5]:333-43.Becker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

Atraumatic Tooth Removal Prior to Implant Insertion

Teeth need to be removed atraumatically to preserve the maximum amount of bone before immediate implant placement.The clinical situation will dictate if the tooth should be removed flaplessly (eg, if it is broken subgingivally, clinicians preference).108

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In the esthetic zone, a buccal flap should not be elevated to reduce recession. Posterior teeth with multiple roots should be sectioned with burs prior to extraction to avoid fracturing the buccal bony plate or the furcation bone.The bur is sunk into the PDL, pressed against the tooth, and circumscribed for 270, avoiding the buccal aspect.

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Burring severs the PDL, creates space (preferably at the expense of the tooth structure), and facilitates tooth removal.Also, Surgical blades (#15, #15c), Periotome (Posterior/Anterior) useful to luxate the root mesialdistally and permit extraction.After extraction, the site is thoroughly degranulated (Molt C2 curette ([HuFriedy, Chicago, IL]) & if necessary, a large round bur. The socket should be carefully examined to be certain that the socket walls are intact.

110

The apex of the socket should be penetrated for implant placement in the usual manner, with attention paid to preparing the recipient site for parallelism and significant extension beyond the apex. This will ensure stability after proper alignment of the implant.111

The surgical guide is placed over the surgical site and a sharp precision drill is used to penetrate the palatal wall of the extraction socket. This drill guides the initial preparation of an osteotomy.The axis of the implant must correspond to the incisal edges of the adjacent teeth or be slightly palatal to this landmark.112

Depending on the size of the extracted tooth and the implant to be placed, the implant should usually exceed the diameter of the root, providing mechanical retention primary implant stability.It is advisable to place an implant a minimum of 3 to 5 mm apically into the bone to attain primary stability if mechanical retention cannot be achieved laterally.Occasionally, it is possible to place a tapered implant into an extraction socket with minimal to no osteotomy preparation, thereby relying on the threads engagement of the bone lateral to the socket walls.

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The stability of the implant can be verified using resonance frequency analysis (RFA). The torque registered on the drilling consul can also be a good indicator of initial implant stability. Torque resistance of 40 Newton centimeters is indicative of initial implant stability.

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Excessive torque should not be applied to the implant because this may strip the implant threads or exert excessive compression on the adjacent bone, potentially leading to bone necrosis and implant loss.Fixture level impressions are frequently made immediately after implant placement facilitates the fabrication of prosthetic abutments and provisional restorations. 115

Abutments and provisional restorations can be inserted onto implants once osseointegration has been verified after a proper healing interval.A healing abutment can be inserted on the top of the implant. It should be even with, or slightly apical to, the adjacent marginal tissues.Interproximal papillae adjacent to the implant can be adapted with interrupted sutures under minimal tension.

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The provisional restoration is then inserted, making certain the pontic is clear of the healing abutment. The provisional restoration should have an ovate pontic to support the adjacent tissues and help preserve the soft tissue anatomy adjacent to the implant.

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The patient is instructed in proper postsurgical care and sutures are removed in 710 days.Restoration of the implant can take place once osseointegration has been confirmed (maxillary anterior region 46 months).

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In the event that an immediately placed implant encroaches upon the maxillary sinus, it might be prudent to postpone implant placement, augment the sinus, allow for bone healing, and then place the implant.119

120XII. THE BONY GAP

-The Jumping DistanceHorizontal DefectHorizontal Defect DimensionPeri-implant Space- The Implant-to-socket Wall SpaceBecker and Goldstein. Immediate implant placement: treatment planning and surgical steps for successful outcome. Periodontol 2000 2008; 47:79-89.

On occasion, the marginal tissues do not adapt to the healing abutment. With a wide gap, connective tissue will form between the coronal implant aspect and the surrounding bone. [Akimoto 1999]With small gaps, on the other hand, bone fill occurs between the implant and the bone, with or without the use of grafting material or barrier membranes. [Botticelli et al 2003, 2004, 2005;]

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Botticelli et al 2004Produced 1.02.5 mm wide circumferential bony defects in dogs. Over a 4-month healing period the circumferential defects healed with bone fill-in. At a few sites, the labial bone adjacent to the extraction socket was reduced in height. In implant sites with reduced labial bone, proper bone healing occurred at the mesial, distal, and lingual defect aspects.122Botticelli D, Berglundh T, Lindhe J. The influence of a biomaterial on the closure of a marginal hard tissue defect adjacent to implants. An experimental study in the dog.Clin Oral Implants Res 2004: 15: 285292.

In another study, bony gaps were left between implants and surrounding bone. Some test sites were augmented with bovine bone, alone or with a resorbable barrier, while other sites were left to heal spontaneously. At 4 months, all the defects filled with newly formed bone and the biomaterial placed in the marginal defect in conjunction with implant installation became incorporated into the newly formed bone tissue. A high degree of contact was established between the bovine bone particles and the newly formed bone.123Botticelli et al 2004 (same authors)Botticelli D, Berglundh T, Lindhe J. Resolution of bone defects of varying dimension and configuration in the marginal portion of the peri-implant bone. An experimental study in the dog. J Clin Periodontol 2004: 31: 309 317.

In practice, when a bony gap is present, no effort is made to surgically advance the flap. A small amount of allograft or alloplast is layered between the bony margin and the implant abutment. This material is left exposed. Within a few weeks some of the material will exfoliate and gingival mucosa will migrate over the exposed material providing an uneventful healing.

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It is important to recognize that placement of bovine bone, allografts, or other substances with or without barrier membranes may support or improve soft tissue contours; however, these materials cannot be relied upon to enhance osseointegration.125

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MechanismIn the early period of healing, allograft particles were surrounded by newly formed bone, confirming their capacity for osseoconduction, but they did not form a real continuity with the socket bone. The internal structure of the particles showed the presence of empty osteocyte lacunae.They had a high degree of biocompatibility with the surrounding tissue and were mainly replaced by newly formed bone at 3 months. The smaller number of residual particles due to higher resorbability than xenografts or other biomaterials allows the regenerated bone structure to be more similar to the original bone. 129

A mineralized bone cortical allograft combined with a collagen membrane allows a significant reduction in buccal and lingual bone resorption, which was higher than observed using mineralized bone cortical allograft alone. The membrane is used as a barrier to hold the mineralized bone cortical allograft in place during the entire healing time. Therefore, the real benefit of using a mineralized bone cortical allograft and membranes in implant surgery is preserving bone volume and enhancing osseointegration, which are the key factors for clinical success.

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Implant-Bone InterfaceIt is reasonable to assume that spaces exist between the implant and the prepared bone site because of the shape of the extraction socket. The implant-bone interface can be classified as type I, II, or lll.131Barzilay. Immediate implants: Their current status. The International Journal of Prosthodontics 1993;6[2].

Barzilay. Immediate implants: Their current status. The International Journal of Prosthodontics 1993;6[2].131

Type IThis can be accomplished when the root is smaller than the implant and is often seen when small teeth are extracted or when the teeth that are extracted have had periodontal disease and the remaining socket size is minimal.The type I interface can also be created when an alveolectomy is performed, thereby allowing the implant to be placed into basal rather than alveolar bone.

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Type IIThe space is present at the coronal aspect of the implant, while the apical portion of the implant is secured in freshly prepared bone.

The Type III situation exists when a space is present along the lateral border of the implant. This may be the reason that the immediate implantation procedure was slow to develop, since this gap may have initially concerned researchers as a possible mode for failure.133Type III

134XIII. SOFT TISSUE MANAGEMENT [DECISION TREE]

135> 2mm< 2mm

136XIV. HISTOLOGICAL OUTCOMES [HEALING FOLLOWING IIP]Vignoletti and Sanz. Immediate implants at fresh extraction sockets: from myth to reality. Periodontol 2000 2014;66:133-52.

Berglundh et al 2003 histologically evaluated the early phases of osseointegration after surgical insertion of endosseous titanium implants into healed crests using the wound chamber model.initially, the empty wound chamber become filled with a coagulum and granulation tissue This granulation tissue was soon replaced by the provisional connective tissue matrix.During 1st week Bone formation starts within the matrix, first in contact with the parent bone by the appositional bone-formation bed, although bone was also formed in direct contact with the implant surface at a distance from the parent bone.137

This primary (or immature) bone was formed by woven bone that was soon remodeled into parallel - fibered and/or lamellar bone and marrow that filled the entire chamber.Percentage of BIC:4- day 6.3%After week 1 24.8%At the end of 12 weeks 65%.138

Vignoletti et al 2009 Studied the osseointegration after implant installation in a fresh extraction socket.1. After 4 hrs -- the interior of the chamber was occupied with non-mineralized tissue, mainly composed of erythrocytes and bone remnants and debris resulting from drilling. Remnants of the periodontal ligament attached to the bundle bone.2. After 1 week -- the wound chamber was mainly filled with granulation tissue, which was rich in fibroblast-like cells within a fibrin-like extracellular matrix. At this time, bone modeling was absent, although abundant areas of bone remodeling were observed in the parent bone.139

3. After 2 weeks -- Bone modeling was manifested, with woven bone formation. New bone formation was observed, both in intimate contact with the implant surface as well as adjacent to the parent bone. A marked angiogenesis that paralleled the osteoblastic activity was noticeable.4. At 4 and 8 weeks -- Both bone-modeling and bone-remodeling events were observed.5. Percentage of BIC:Day 0 10-15%; Limited to the thread tip level of the implant.After week 1 Decreased to 5%Upto 8 weeks 45%.

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Comparison between both studies demonstrates that the processes of de-novo bone formation and osseointegration are similar, both quantitatively and qualitatively. However, in the immediate implant model, a more pronounced osteoclastic remodeling phase was observed in the first 2 weeks, which translated to a decrease of approximately 10% of the BIC between 4 h and 1 week after implant insertion.

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Greenstein and Cavallaro. Immediate Dental Implant Placement: Technique, Part 1. Dentistry Today 2014.

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144XV. IIP IN INFECTED SITES

Introduction Some authors consider implant placement in chronic apical lesions to be a contraindication.[Tolman 1991; Barzilay 1993] In fact, it has been postulated that periapical and periodontal lesions have a negative effect on osseointegration, resulting in implant failure. [Werbitt 1992].On the contrary, it has been demonstrated that immediate implants placed into infected post-extraction sockets are a predictable procedure with success rates close to 92% [Lindeboom et al 2006].More recent literature, however, has investigated placement into sites exhibiting periapical pathosis with successful outcomes. [Naves, Del Fabbro, Crespi, Marconcini].145

Indications Periapical granuloma.Periapical cysts.Periradicular lesions.Ligature-induced periodontal disease.Endo-perio lesions.Recurrent endodontic lesions.Chronic periapical or periodontal pathology.Fistula, suppuration or combination lesions.Root fracture, resorption, perforations.Unfavorable crown-root ratio.Subacute periodontal infection.

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Contraindications Recurrent infections.Sites with uncontrolled infections.Sites with inadequate supporting bone.Systemic uncontrolled diabetes, smoking..147

148XVI. LITERATURE REVIEW

Waasdorp et al 2010Addressed the review on:Does the presence of infection compromise the osseointegration of immediately placed implants?Does the presence of infection compromise immediate implant placement success?What protocols have been used to address the infection prior to immediate implant placement?149The diagnosis of infection is often clinically based; clearly, periapical lesions which present with a similar radiographic appearance can differ histologically.Waasdorp et al. Immediate Placement of Implants Into Infected Sites: A Systematic Review of the Literature. J Periodontol 2010;81:801-808.

Waasdorp et al. Immediate Placement of Implants Into Infected Sites: A Systematic Review of the Literature. J Periodontol 2010;81:801-808.149

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Data from HUMAN studies 5 Case reports/Case series + 3 Comparative Clinical studies151Novaes & Novaes 1995 [1st case report]3 patients, each with 1 IIP. [recurrent endo/periapical radiolucency]100% success with a proof of principle patient must be placed on penicillin V 24-48 hours before the procedure and maintained on medication for 10 days.Villa and Rangert 200520 patients 97 implants [endo/perio]100% survival.Villa and Rangert 2007100 maxillary implants [76 in infected sites vs. 24 in healed sites] endo/perio/root fracture.97.4% survival rate.Casap et al 200730 implants into infected sites in 20 patients [periodontal cysts, endo-perio, periapical, chronic periodontal infections]97.7% survival rate.Complications membrane exposure, minimal attached gingiva, pseudomembranous colitis.Naves 20093 IIP in 1 patient with 3 years follow-up [chronic periapical]100% survival.

Lindeboom 2006 [1st prospective randomized study]50 patients (Test - 25 IIP in infected sites vs. Control 25 in delayed installation 3months post-extraction [chronic periapical pathology].Follow-up 1 year92% vs. 100% survival in Test vs. Control group. Microbes culturedfrom sockets.F. nucleatum andP. micra were most prevalent.Seigenthaler et al 200729 patients completed 29 implants (Test 13 vs. Control 16)[periapical pathology, suppuration, fistula, combination]Follow-up 1 year100% survival.Del Fabbro et al 200930 patients 61 IIP in [Chronic periapical].Follow-up 10-21 months.98.45% survival rate.

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Del Fabbro 2009 Evaluated the clinical outcome of implants immediately placed into fresh extraction sockets of teeth affected by chronic periapical pathologic findings, using plasma rich in growth factors (PRGFs) as an adjunct during the surgical procedure.A total of 61 transmucosal implants were immediately installed in 30 partially edentulous patients after extraction of teeth with chronic periapical lesions.All implants used had an acid-etched surface. Before placement, the implants were embedded carefully in liquid PRGFs to bioactivate the implant surface.153Del Fabbro M, Boggian C, Taschieri S. Immediate implant placement into fresh extraction sites with chronic periapical pathologic features combined with plasma rich in growth factors: Preliminary results of single-cohort study. J Oral Maxillofac Surg 2009;67: 2476-2484.

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The implant success and survival rate was 98.4% after 1 year of function (100% in the maxilla and 96.8% in the mandible).According to the lesion type, 100% and 96.2% of implant success was recorded in sites affected by endo-periodontal or endodontic lesions, respectively.Why PRGFs? It is particularly indicated for immediate post-extraction implants; combined with minute bone chips obtained during drilling procedure, it could fill the gap between the implant surface and socket walls, providing an osteoconductive, autologous graft that replaces and improves the bone substitutes commonly used. The implant surface adsorbed the protein-rich material, and osseointegration was enhanced when the surface was covered with PRGFs.155

Data from Waasdorps review demonstrated High levels of implant survival in the presence of periodontal and periapical infections.

Key points with respect to treatment protocol --- Complete and thorough debridement of the socket..Achieving primary stability..Use of systemic antibiotics..156

Fugazzotto in 2012Retrospectively assessed the implant survival rates when immediate implants were placed in maxillary incisor region with [mean follow up 64 months] and without periapical pathology[mean follow up 62 months] in the same patient (total 64 patients).Yielded cumulative survival rates of 98.1 and 98.2 for implants placed in sites with periapical pathology and implants placed in sites without periapical pathology, respectively.157Paul A. Fugazzotto. A Retrospective Analysis of Implants Immediately Placed in Sites With and Without Periapical Pathology in Sixty-Four Patients. J Periodontol 2012;83:182-186.

Paul A. Fugazzotto. A Retrospective Analysis of Implants Immediately Placed in Sites With and Without Periapical Pathology in Sixty-Four Patients. J Periodontol2012;83:182-186.

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Minimal Requirements

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Jofre et al 2012Reported 31 case series treated according to the protocol of asepsis after extraction of infected teeth, and immediate implant placement and provisionalization, and, presented a classification of implant surface compromise in contact with previously infected tissue [CRAI].159Jofre et al. Protocol for Immediate Implant Replacement of Infected Teeth. Implant Dent 2012;21:287294

Jofre et al. Protocol for Immediate Implant Replacement of Infected Teeth. Implant Dent 2012;21:287294159

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Marconcini et al 2013Evaluated the 12 month clinical success of 20 single-tooth implants placed in infected fresh sockets.Prophylactic antibiotic treatment was prescribed for each patient (2 g amoxicillin, 1 hour before surgery; thereafter, 1 g twice daily for 5 days).Twenty teeth were extracted as a result of an infection. Second stage surgery was performed 4 months after the initial procedure. The healing period was uneventful for all the patients. All the implants were osseointegrated. At the end of the 12-month follow-up period, patients were asymptomatic and showed no signs of infection or bleeding when probed.

163Marconcini et al. Immediate Implant Placement in Infected Sites: A Case Series. J Periodontol 2013;84:196-202.

Marconcini et al. Immediate Implant Placement in Infected Sites: A Case Series. J Periodontol 2013;84:196-202.163

An infected tooth assumes the presence of bacteria in the socket. A direct consequence of the presence of bacteria in the socket is the formation of granulation tissues that, at the same time, play a role in the inflammatory response to bacteria as well as a barrier for the bone. To conclude from the study, the control of the inflammation process in the implant site by an early antibiotic prophylaxis may establish a new homeostatic balance between bone resorption and new bone formation, thus reducing risks of implant failure.164

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XVII. RECOMMENDATIONS FOR CLINICAL PRACTICE166

When considering which implant protocol might be most appropriate, the clinician must take into consideration different factors: the patient; the location; and the surgical protocol.As for any other surgical implant protocol, the patient should be free from oral infections and all previous oral conditions should be treated before surgical implant placement.In patients affected by systemic diseases influencing wound healing after implant surgery, such as diabetes, their systemic status must be controlled before implant installation.167

In terms of the location, the factors of major concern when using the immediate implant protocol are:the thickness and the integrity of the socket bone walls, mainly the buccal crest, as well as the gingival biotype.

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From a surgical point of view, the implant design and implant position may be the factors of major concern.Hence, when using the immediate placement protocol, the buccal positioning of the implant and the use of implants that are too congruent with the socket anatomy (tapered implants) should be avoided.Implant placement must therefore be guided by the ideal prosthetic position as well as by the assurance of primary stability in the apical portion of the socket and the creation of an adequate gap dimension (> 2 mm) between the implant surface and the inner buccal bone plate in the coronal portion, to allow for adequate bone healing.169

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